What is Evaluation and management Coding?

Introduction:

Evaluation and Management coding was introduced by the American Medical Association and CMS in 1993. Evaluation and management coding commonly known as E/M coding or E&M coding, is key to maximizing reimbursement and maintaining proper documentation. Many physicians lose revenue every day because they under code their services.

The basic E/M coding rules, providers can more accurately code with confidence and ensure that their documentation is in compliance. Electronic Health Records (EHR) software is of great value in facilitating this process but there is no substitute for being well versed with coding rules. This article describes some of the basic components of E/M coding. E/M coding is the process by which physician-patient encounters are translated into five digit CPT codes to facilitate billing. CPT stands for "current procedural terminology." These are the numeric codes which are submitted to insurers for payment. Every billable procedure has its own individual CPT code. Know more at Medical Coding training

The Key Components of E/M Documentation: There are Three key components of the E/M guidelines:

One: Patient history

Two: Examination

Three: MDM (medical decision-making)

History:

Chief complaint: Chief Complaint (CC) is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter.T he CC is generally the patient’s stated reason for the encounter. For example, patient complains of upset stomach, aching joints, and fatigue. The medical record should clearly reflect the CC.

History of present illness: HPI is a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present.

Review of symptoms: The ROS is a system-by-system review of body functions that begins during the initial patient interview and is completed during the physical exam. According to Huffman’s Health Information Management, "the ROS is an inventory of symptoms to reveal subjective symptoms that the patient either forgot to describe or which at the time seemed relatively unimportant.

Examination:

This part is all objective, observable info noted by your physician. To make these observations the doctor needs to see, hear, feel, or smell things and report them. As coders, we compartmentalize them into body systems, much like the ROS with the important distinction that exam elements are objective notes made from the physician’s inspection of the patient.

The levels of E/M services are based on four types of examination:

Problem Focused – A limited examination of the affected body area or organ system? Expanded Problem Focused – A limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s)? Detailed – An extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s)? Comprehensive – A general multi-system examination or complete examination of a single organ system (and other symptomatic or related body area(s) or organ system(s) – 1997 documentation guidelines).Know more about Medical Coding Online Training

Medical Decision Making:

This level is assigned based on how complex the case is for your doctor. Factors in consideration are whether your problem is new or one she has treated you for previously, what type of medical info she has to review (labs, old records, x-rays), and how much risk of complications is involved. The number of diagnoses and/or the number of management options that must be considered. The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed.