Portfolio Project Week 6
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MCCG240- Evaluation and Management
Week 2: Portfolio Project
E/M Overview
Brianna Narolis
Evaluation and Management(E/M) coding is a coding process used in the medical billing
field. The E/M codes are a coding system that involves the use of CPT codes from the range of
99202-99499. The codes happen to represent services that are provided by a physician or other
qualified healthcare professional. The codes are utilized when the provider is involved in either
evaluating or managing a patient's health. There are three key components to consider when
using E/M codes which are Patient’s History, Examination, and Medical Decision Making
(MDM). These visits for the patients can be in the office, hospital, home, or preventative
medicine. The patients are diagnosed and treated for injuries and or illnesses by their healthcare
professionals.
When it comes to choosing an Evaluation and Management code there are some
abbreviations you should understand. There are a lot of different abbreviations you may come
across in the patient’s medical chart. Some of the abbreviations are HPI- History of Present
Illness, CC- Chief Complaint, ROS- Review of Systems, MDM- Medical Decision Making,
PMH- Past Medical History, FH- Family History, SH- Social History, and PFSH- Past Medical,
Family and Social History. When coding using CPT codes there are some symbols associated
with them. For an add-on code, it is a (+) symbol. This described each additional. A blue triangle
is a revised code. A red dot is an indication of a new procedure code.
A circle with a line through
it means that the codes are exempt from using the modifier 51. The lightning bolt is used when
vaccine codes are pending FDA approval.
The two green triangles next to each other are to say
new and resided text than the procedure descriptors. A # symbol is used when the code is not
placed numerically. A star is used to identify codes used in telemedicine, attached with the 95
modifier. Evaluation and management coding you will see punctuation used. The semicolon is
used for a code that is inclusive and stands alone. A comma is used to separate each individual
from one another.
New and Established Patients are described a little differently than each other. New
patients are one who has not received any professional services from a physician, or another
physician of the same specialty who belongs to the same group practice within the past three
years. The Established Patient is one who has received professional services from the physician/
qualified health care professional or another physician/ qualified health care professional of the
exact same specialty and subspecialty who belongs to the same group practice, within the past
three years. Evaluation and Management coding can differentiate by the encounter locations. The
Place of Service is where the patient had gotten their service or care done.
The Type of Service
depends on what service was given to that exact patient when they were seen by the healthcare
professional. The Evaluation and Management codes will always all begin with a 99 and must
contain 5 digits. Any code that is assigned to a patient with be dependent on the visit and what
kind of care the patient receives while at a physician.
In Evaluation and Management coding there are some contributory factors to look at
when you choose the correct code. When it comes to coding you have to look at the four
different types of Medical Decision Making (MDM) straightforward, low, moderate, and high.
Straightforward is when the patient has one self-limited or minor problem. An example of a
Straightforward code is 99202- Office or other outpatient visit for the evaluation and
management of a new patient which requires a medically appropriate history and/or examination
and straightforward medical decision making, 15-29 minutes in total time spent on the date of the
encounter. Low is when the patient has two or more self-limited or minor problems, or one stable
chronic illness, or one acute uncomplicated illness or injury. An example of a low code is 99231-
Subsequent hospital inpatient or observation care per day, for evaluation and management of a
patient, which requires a medically appropriate history and/or examination and a straightforward
or low level of medical decision-making. Moderate is when the patient can either have one or
more chronic illnesses with mild exacerbation progression, or side effects, two or more stable
chronic illnesses, or an undiagnosed new problem with uncertain prognosis. An example of a
moderate code is 99344- Home or Residence visit for the evaluation and management of a new
patient, which requires a medically appropriate history and/or examination and a moderate level
of medical decision making, the total time on the date of encounter 60 minutes must be meet or
exceeded. High is when the patient has one or more chronic illnesses with severe exacerbation,
progression, or side effects of treatment, acute or chronic illnesses, or injuries that pose a threat
to life or bodily function. An example of a high code is 99285- Emergency department visit for
the evaluation and management of a patient which requires a medically appropriate history
and/or examination and a high level of medical decision making.
When using Evaluation and Management codes you will have to look at the three
elements associated with them to help you code. The elements are the number and complexity of
problems addressed during the encounter, the amount and/or complexity of data to be reviewed
and analyzed, and the risk of complications/and/or morbidity or mortality of patient
management. The number and complexity of problems addressed during the encounter is a
problem as a disease, condition, illness, injury, symptom, sign, finding, complaint, or other
matter addressed at the encounter with or without a diagnosis being established at the time of the
encounter with the physician. The amount and/or complexity of data to be reviewed and analyzed
is used to recognize each unique test, order, or document to meet the requirements for each level
of MDM. The tests can include imaging, laboratory, psychometric, or physiologic data. The
difference between single or multiple unique tests is based on the appropriate CPT codes for the
tests being done. The risk of complications/and/or morbidity and mortality of patient
management means the probability and/or consequences of an event. The assessment of the level
of risk is affected by the nature of the event under consideration. For the purpose of medical
decision-making, the level of risk is based upon consequences of the problem(s) addressed at the
encounter when appropriately treated. Risks also include Medical decision-making related to the
need to initiate or forego further testing, treatment, or hospitalization.
When coding for Evaluation and Management, sometimes you will need to add a
modifier to the code. The modifiers are added to the end of the E/M code to show that the code
was modified slightly. Modifier 24 is used for an unrelated evaluation and management service
by the same physician or other qualified healthcare professional during the post-operative period.
Modifier 25 is used to indicate that the patient's condition required significant, separately
identifiable Evaluation and Management (E/M) service above and beyond that associated with
another procedure or service being reported by the same physician or other qualified healthcare
professional on the same date. The modifier 57 is used to indicate an E/M service resulted in the
initial decision to perform surgery either the day before a major surgery or the day of a major
surgery. It is applied when the E/M service results in a decision to do the surgery. Modifiers used
of Evaluation and Management codes are 24, 25, and 57.
When it comes to E/M guidelines there are seven categories Office or Other Outpatient
Services, Hospital inpatient and Observation Care Services, Consultations, Emergency
Department Services, Nursing Facility Services, Home or Residence Services, and Prolonged
Service With or Without Direct Patient Contact on the Date of an E/M Service. Office or Other
Outpatient Services are used to report evaluation and management services provided in the office
or in an outpatient or other ambulatory facility. The codes range from 99202-99215. Hospital
Inpatient and Observation Care Services are used to report initial and subsequent evaluation and
management services provided to hospital inpatients and to the patients designated as hospital
outpatient “observation status”. These codes for Observation range from 99217-99226, and for
Inpatient range from 99221-99239. Consultations are a type of evaluation and management
service provided at the request of another physician, other qualified healthcare professional, or
appropriate source to recommend care for a specific condition or problem. These codes range
from 99241-99255. Emergency Department Services are used to report evaluation and
management services provided in the emergency department. No distinction is made between a
new or established patient when it comes to the emergency room. These codes range from
99281-99288. Nursing Facility Services are used to report evaluation and management services
to patients in nursing facilities and skilled nursing facilities. They are used to report E/M services
provided to patients in a psychiatric residential treatment center and immediate care facility for
individuals with intellectual disabilities. These codes range from 99304-99318. Home of
Residence Services are used to report E/M services provided in a home or residence. They are
also used when residence is an assisted living facility, group home, custodial care facility or the
residential substance abuse treatment facility. These codes range from 99341-99417. Prolonged
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Service With or Without Direct Patient Contact on the Date of an E/M Service are only reported
with the highest level of office/ outpatient visit E/M code when the time requirements have been
satisfied. These are based on time and not medical decision-making. These codes range from
99354-99417.
An initial service is when a patient has not received any professional services from the
physician or other qualified healthcare professional or another physician or other qualified
healthcare professional of the exact same specialty and subspecialty who belongs to the same
group practice during the inpatient, observation, or nursing facility admission and stay. A
subsequent service is when the patient has received professional services from the physician or
other qualified healthcare professional or another physician or other qualified healthcare
professional of the exact same specialty and subsequently who belongs to the same group
practice during the admission and stay. The difference between an Initial service and a
Subsequent service is that an initial is when the patient has not received care from anyone of the
exact same specialty or subspecialty who belongs to the same group practice, during the
inpatient, observation, or nursing facility admission and stay. Subsequent is when the patient
already received care from the exact same specialty or subspecialty who belongs to the same
group practice, during admission and stay.
Example Coding patient case study. In this patient's case, I will be explaining the level of
the examination for Rodney, as well as going over the case and assigning the correct ICD-10-CM
and CPT E/M codes. This example is using Rodney Giles, a 53-year-old patient with a history of
RA. He is currently taking Humira and Sulfasalazine. He has also been on MTX but was stopped
because of his lung problems. He also has lung lesions that are being followed by pulmonary. He
was cleared to restart Humira after his hospitalization. He does not believe that the Humira is
working for him. He is currently due for his TB test. He wants to discuss possibly switching
medications. His rate of pain is an 8/10 with his morning stiffness for about 4 hours each
morning. He would like to see what other options are available for him. He would like to try
Enbrel. He is going to be given Prednisone 5mg daily during his wash-out period. After the
washout period, he will be able to start Enbrel. They discussed exercise and pool aerobics.
Chief complaint: Bilateral hand pain
Past medical history: RA, DDD.
Medications: Humira, Sulfasalazine, Prednisone, and Ibuprofen.
Impression: RA involving both of his hands, DDD of lumbar spine
For Rodney’s case, I started by assigning M06.9- rheumatoid arthritis, unspecified,
M51.36- other intervertebral disc degeneration, lumbar region, and Z79.899- other long-term
(current) drug therapy. The Evaluation and Management code for Rodney’s case is 99244- Office
or Outpatient consultation for a new or established patient. Which requires a medically
appropriate history and/or examination and a high level of decision-making, Total time on the
date of encounter is 55 minutes and must be met or exceeded.
An example case scenario of an outpatient office visit is the case of Estel Capleton. A
new patient is here for a hospital follow-up for a large ovarian mass that looks malignant. The
patient stated she noticed moderate to severe pain in her left lower abdomen and its been going
on for a week. When it got worse she went to the Emergency Room and was noted to have a very
large ovarian cyst, suspicious for cancer. Today her pain is about an 8/10 particularly when she
moves and lays on her left side. She feels that pain is less when she lies on her right side. She has
nausea, no vomiting, and has no appetite. She had a little constipation, but now more like
diarrhea.
She was diagnosed with an ovarian cyst N83.209- unspecified ovarian cyst. Unspecified side.
She was given Norco for the chronic pain Z79.1- long term (current) use of non-steroidal anti-
inflammatories. She was also having chronic pain so I chose to code that G89.29- other chronic
pain. She was also a new patient being seen for a follow up from the ER so I chose 99202- Office
or other outpatient visit for the evaluation and management of a new patient, which requires a
medically appropriate history and/or examination and straightforward medical decision making.
Sources
AMERICAN MEDICAL ASSOCIATION. (2022).
Cpt Professional 2023 And E/M Companion
2023 Bundle
. AMERICAN MEDICAL ASSOCIAT.
Evaluation and Management Codes - What are E&M Codes?
(n.d.). ForeSee Medical.
https://www.foreseemed.com/evaluation-management-codes
Evaluation and Management (E&M) Guidelines
. (2018, January 4). CUIMC Office for Billing
Compliance.
https://www.compliance.cuimc.columbia.edu/compliance-standards/evaluation-and-
management-e-m-guidelines
Wilson, K. (2023, January 25).
New vs Established & Initial vs Subsequent
.
Kwadvancedconsulting.com.
https://kwadvancedconsulting.com/new-vs-established-initial-vs-
subsequent/
(2023). Aapc.com. https://www.aapc.com/resources/what-are-e-m-codes
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