The codes for evaluation and management services are a subset of the Current Procedural Terminology, or CPT, the code set published and maintained by the American Medical Association (AMA), and refer to services provided by physicians in evaluating patients and managing their medical care. The coding and medical billing for E/M (Evaluation and Management) services are especially complicated.
The codes are used to determine the level of services that a physician provides, and are then used to determine reimbursement of those services. E/M codes are categorized according to site and/or type of service provided (office, outpatient, consultation, emergency department). Within these categories, the codes are then subdivided according to initial and subsequent care. Within these subdivisions, the codes are then itemized by the specific elements of service provided.
The reference of choice for determining these codes is the CMS’ Documentation Guidelines for Evaluation and Management Services. There are actually two different editions of this guide, so be sure you choose one or the other and are not referring to both.
When coding for E/M, three main descriptors determine the level of service: History, Examination, and Medical Decision Making. Both history-establishment and examinations are evaluated based on whether they are problem focused, expanded problem focused, detailed, or comprehensive. Medical Decision Making services are evaluated on the number of diagnoses or management options, the complexity of data to be reviewed, and the risk of complications and mortality.
Besides these three main descriptors, E/M service codes also take into account counseling, coordination of care, nature of presenting problem, and time. When 50% or more of the E/M service duration is spent on counseling or coordination of care, time is the primary factor in determining service level.
For more specifics on coding and billing for E/M services, refer to the CMS guide.
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