EM CODING

-XYLUM MEDICAL CODING ACADEMY

EM CODING ?

• The utilization of E&M codes is a fundamental aspect of medical billing.

• Developed by AMA and CMS, Updated yearly [Release, Effective and Implementation]
• E/M coding is the process by which physician-patient encounters are translated into five digit
CPT codes to facilitate billing.
• These codes determine the reimbursement level for the time and effort spent by healthcare
professionals in assessing and managing a patient's care.
• These are the numeric codes which are submitted to insurers for payment.
• Use of CPT codes from the range 99202 to 99499 which represent services provided by a
physician or other qualified healthcare professional
• Codes for procedures like surgeries, radiology and diagnostic tests, and certain treatment
therapies are not considered evaluation and management services.
EM CODING ?

• E&M codes are used to represent the various physician and provider services
primarily centered around the evaluation and management of patients.
• E&M coding is not about procedures or tests but rather focuses on the
cognitive services provided by healthcare professionals, such as patient
consultations, physical examinations, and medical decision-making processes.
• These codes determine the reimbursement level for the time and effort spent
by healthcare professionals in assessing and managing a patient's care.
• Inaccurate or inappropriate E&M coding can lead to either underbilling, which
means a loss of revenue for the healthcare provider, or overbilling, which can
result in audits, fines, and even legal action.
 MDM
TIME
HISTORY
AND/OR
EXAM

Physicians use E&M

E&M GUIDELINES
CPT codes to bill for
services and obtain
reimbursement. The
AMA is responsible for
creating the OTHER
evaluation and SR
CONSIDERATION
management codes SERVICES S
and the guidelines for
how those codes are
utilized.
IMPORTANT GUIDELINES OF EM CODING

Guidelines for selecting the appropriate evaluation and

management codes :
• History and/or Examination
• Medical Decision Making (MDM)
• Time
• Services Reported Separately
• Other Considerations
HISTORY AND/OR EXAMINATION
• The nature and extent of the history and/or
physical examination are determined by the
treating physician, and it should be medically
appropriate.

• However, the extent of the physical examination

is not an element in selection of the level of
office or other outpatient codes.

• Previously we had a selection based on the

elements provided under Physical examination
MDM
•The number and complexity of the problems that are addressed at an
encounter

•The amount of data to be analyzed. Data can include medical records, tests,
and other information that can be reviewed during or for the encounter

•Tests, documents, orders, or independent medical histories

•Independent interpretation of tests

•The risk of complications due to the morbidity or mortality of patient

management decisions made at the visit associated with the patient’s problem,
diagnosis, or treatment

•Four types of MDM are recognized: straightforward, low, moderate, and high,

•AMA has a table with guidelines

 Amount &
Number and Complexity of
Complexity of data
Problems reviewed or
addressed MDM
analyzed

Risk of
complications
/ Morbidity
and Mortality
 TIME
• The amount of time or the total time of the encounter on the date of the encounter determines the appropriate
evaluation and management CPT codes. This can include face-to-face and non-face-to-face time personally spent
by the physician and includes the following items:
• Preparing to see the patient (e.g., review of tests)
• Obtaining and/or reviewing separately obtained history
• Performing a medically appropriate examination and/or evaluation
• Counseling and educating the patient/family/caregiver
• Ordering medications, tests, or procedures
• Referring and communicating with other health care professionals (when not separately reported)
• Documenting clinical information in the electronic or other health record
• Independently interpreting results (not separately reported) and communicating results to the patient/
family/caregiver
• Care coordination (not separately reported)
• It excludes any travel time, time spent on any procedure which is being billed separately, as well as teaching
unrelated to that specific patient.
 OTHER CONSIDERATIONS
•New or established patient

•Prolonged services are codes for when a physician

provides direct patient contact that is provided
beyond the usual service either in the inpatient or
outpatient setting.

•A different set of codes are used for prolonged

services without direct patient contact.
SERVICES REPORTED SEPARATELY
• Any specifically identifiable procedure or service
performed on the date of E/M services to be
reported separately.

• Tests that do not require separate interpretation

are considered as part of MDM.

• If required to use appropriate modifier with CPT ex.

25 and 26
In the Evaluation and Management section
(99202-99499), there are many code categories. Each
category may have specific guidelines, or the codes
may include specific details.

These E/M guidelines are

written for the following categories:

• Office or Other Outpatient Services

• Hospital Inpatient and Observation Care Services
• Consultations
• Emergency Department Services
• Nursing Facility Services
• Home or Residence Services
• Prolonged Service With or Without Direct Patient
Contact on the Date of an Evaluation and Management Service
 When billing E/M services, you must select the CPT code that
best represents the following:

 Setting of service, whether office or

outpatient setting, hospital, emergency
department, or nursing facility

 Patient type, whether new or established

 Level of E/M service provided, typically the

more complex visit correlates with a higher
level code
EM CLASSIFICATIONS

NEW
INI
HOSPITAL
OFFICE VISITS INPATIENT/OB
V SU
ES
B
T

CONSULTATION
S
New and Established Patients
Solely for the purposes of distinguishing between
new and established patients, professional services
are those face-to-face services rendered by physicians
and other qualified health care professionals who may
report evaluation and management services. A new
patient is one who has not received any professional
services from the physician or other qualified health
care professional or another physician or other
qualified health care professional of the exact same
specialty and subspecialty who belongs to the same
group practice, within the past three years.

Established patients
An established patient is one who has received
professional services from the physician or other
qualified health care professional or another physician
or other qualified health care professional of the
exact same specialty and subspecialty who belongs
to the same group practice, within the past three
years.
NEW VS ESTABLISHED
Received any professional services from the same
physician or another physician in group of same
speciality within the last three years?

Yes No

Exact same speciality

Yes No

Exact same speciality

Yes No
 INITIAL AND SUBSEQUENT
SERVICE
“An initial service may be reported when the
patient has not received any professional services
from the physician or other qualified health care
professional (QHP) or another physician or QHP of
the exact same specialty and subspecialty who
belongs to the same group practice during the
stay.”

An subsequent service may be reported when

the patient has not received any professional
services from the physician or other qualified
health care professional (QHP) or another
physician or QHP of the exact same specialty and
subspecialty who belongs to the same group
practice during the stay.”
SPLIT OR SHARED VISITS
A split/shared visit is an E/M visit in a hospital or other
facility setting that is performed in part by both a physician
and an NPP who are in the same practice group. The
Centers for Medicare & Medicaid Services (CMS) also has
finalized that a split/shared visit can be provided to a new
or established patient and for an initial or subsequent visit.
Split/shared visits are not provided in the office setting.

Modifier -FS (split/ shared E/M visit) must be appended to

the E/M CPT® code on the claim
• Multiple EM services on same
date
• Selection of EM levels based on
guidelines
• Commonly encountered
procedures
• Time calculations and coding
TOPICS TO BE COVERED:
• ICD GUIDELINES
• CPT PROCEDURES IN OP AND IP SETTINGS
• TRAINING ON MODIFIERS
• VACCINE ADMINISTRATION CPTS AND GUIDELINES
• ANNUAL WELLNESS VISIT
• TELEHEALTH VISITS
• CRITICAL CARE CODING
ANNUAL WELLNESS VISIT
• The purpose of the Annual Wellness Visit is to develop or update a personalized prevention plan based on
current health and risk factors.

• Note: The first Annual Wellness Visit cannot take place within 12 months of a member’s “Welcome to Medicare”
preventive visit. However, members do not need to have had a “Welcome to Medicare” visit to be covered for
Annual Wellness Visits after they have been enrolled in Part B Medicare for 12 months.

• An initial Annual Wellness Visit code is documented using G0438, subsequent Annual Wellness Visits are
documented using code G0439.

An Annual Wellness Visit is covered when performed by a:

 Physician (a doctor of medicine or osteopathy)

 Qualified non-physician practitioner (a physician assistant, nurse practitioner, or certified clinical nurse
specialist) Medical professional (including a health educator, registered dietitian, nutrition professional, or other
licensed practitioner), or a team of medical professionals who are directly supervised by a physician (doctor of
medicine or osteopathy)
Takeaways :
• E&M CPT codes are a vital component of healthcare billing and coding

• Correct application of E/M codes ensures that this care is accurately

captured and reimbursed.

• Inaccurate or incorrect billing can lead to criminal and/or civil

penalties.

• Knowingly submitting false claims to obtain a federal health care

payment for which no entitlement would otherwise exist is considered
Medicare fraud.

• Misusing codes on a claim, such as up-coding or unbundling codes is

considered Medicare abuse

• The AMA, CMS and AAPC (American Association of Professional Coders)

provide excellent resources and learning tools for CME, CE and self-
education.