E&M Codes and How to Use Them

As a practitioner, especially if you’re a wound care specialist, you probably know how to perform a wound assessment, make dressing changes, and follow treatment plans. You’re even familiar with the alphabet soup of healthcare terms and jargon that colleagues toss your way throughout the day. But what can stump even the most experienced wound care specialists? The proper use of E&M codes. 

Even if you don’t know much about them, practically anytime you see a patient, provide a service, or perform a procedure, E/M codes might be involved. Therefore, while these codes might not be your first thought when providing care, they’re essential for wound care providers to understand, as they can directly affect a practice’s bottom line. So, let’s explore what E & M CPT codes are, how they work, and why they’re important even in wound care. 

What Are Current Procedural Terminology (CPT) Codes?

Before we can dive into E/M codes, it is helpful to understand their origins. And in order to do that, we must first discuss CPT codes. 

The Journey to CPT Codes

For decades, healthcare professionals would describe the medical services they performed through narrative documentation. They’d often provide thorough descriptions, using their own terminology and frequently biased opinions, of a patient’s concerns and their treatment plan. While descriptive, physicians’ notes were inconsistent across the board, and this approach wouldn’t work well with the rise of health insurance. 

It became clear that qualified healthcare professionals needed a way to describe the professional services they provided in a manner that other parties could understand. Therefore, in 1966, the American Medical Association (AMA) created CPT codes, which are described as “A uniform language for coding medical services and procedures to streamline reporting, increase accuracy and efficiency.”

Different Types of CPT Codes

As you know, there are thousands of healthcare services and procedures, and as a result, there are just as many (if not more) CPT codes. To keep up with them all, they’ve been classified into three categories.

• Category I: These describe medical services and procedures completed by a physician or qualified healthcare professional. The majority of CPT codes fall under this category. There are six primary sections of Category I codes, and they follow a specific sequence based on which ones are most commonly used:
  • Evaluation and Management 
  • Anesthesia 
  • Surgery
  • Radiology 
  • Pathology and Laboratory 
  • Medicine 
• Category II: Supplemental tracking codes utilized for performance measurement. 
• Category III: Temporary tracking codes used to collect data and the assessment of services and procedures when there’s new technology. 

What Are E&M Codes?

Based on what we’ve described so far, you’ve likely gathered that E&M stands for “evaluation and management”, codes are a subset of Category I CPT codes. But still, what does that actually mean in practice? 

As indicated by their name, E/M codes are used when visits involve evaluating or managing a patient’s health. Therefore, if a patient comes in and you’re completing tasks like educating their family member, ordering a wound culture, or completing medical decision-making, those would fall under E/M services. 

It’s also crucial to recognize that E/M codes do not include procedures, like surgery or certain treatment therapies. So, if a patient visits your office for debridement or negative pressure wound therapy (NPWT), those wouldn’t be considered E/M services, and therefore, an E/M code shouldn’t be applied. 

In addition, every procedure code has an underlying E/M component, as it’s expected that a practitioner would need to assess the medical necessity of the procedure, the patient’s health status, and other relevant factors. For instance, if a practitioner evaluates a wound and decides debridement is needed, this simply falls under the debridement code. Because of this, a separate, billable E/M code isn’t required. 

What Do E/M Codes Look Like?

E/M codes are five characters long, numerical, and fall under the 99202 to 99499 range. They’re organized into over two dozen broad categories based on where the service was provided and the varying range of patient care. Consider the following three examples of E/M code categories:  

• 99202 – 99215: Office or Other Outpatient Services
• 99221 – 99239: Hospital Inpatient and Observation Care Services 
• 99341 – 99350: Home or Residence Services 

Subcategories for E&M CPT Codes

Some of the E/M code categories have subcategories, where you can select between different options. For instance, they may be divided between new patients and established patients, as seen with the Office and Other Outpatient Services category. 

For context, it appears like this: 

• 99202 – 99205: New Patient
• 99211 – 99215: Established Patient

Service Levels for E/M Codes

Each category and subcategory of E/M services can then be further classified into levels of E&M services; there are usually three to five E/M service levels under each one for reporting purposes. In addition, every level has its own E/M code. 

Admittedly, the codes being layered in this way can be confusing. Still, the reason they are broken down in this manner is to acknowledge the various work, skills, time, and knowledge that may go into these different encounters.

Essential Guidelines for Selecting E/M Service Level 

Now that you know what evaluation and management codes look like, how are wound care providers supposed to know which code level to choose? 

Usually, the E & M CPT code level is determined by one of two things: the extent of medical decision making (MDM) or the total time spent on the date of the encounter.

The Types of MDMs

Currently, the AMA recognizes four types of MDM: straightforward, low, moderate, and high. From there, the type of MDM is defined by three elements, which are: 

• The number and complexity of problems addressed during the encounter
• The amount and/or complexity of data that needs to be reviewed and analyzed
• The risk of complications and/or mortality, or mobility in patient management 

In order to qualify for a particular MDM level, you have to meet two out of three elements for that level of decision-making. Keep in mind that there are several additional rules for each element. Therefore, it’s crucial that wound care providers thoroughly review the E/M guidelines to understand each one and how they help determine the MDM level. 

An Example of Criteria Required for a Low Level of Medical Decision Making

To give you some perspective, we’ll go over what criteria may be needed to qualify for a low level of MDM. Remember, at least two out of three of these elements must be met. 

• Number and complexity of problems 
  • Two or more self-limited or minor problems; or
  • One stable, chronic illness; or
  • One acute, uncomplicated illness or injury; or
  • One stable, acute illness; or
  • One acute, uncomplicated illness or injury requiring hospital inpatient or observation level of care
• Amount/complexity of data (Must meet the criteria for at least one of the two categories) 
  • Category 1 (Tests and Documents): Any combination of two from the following:
    • Review of prior external note(s) from each unique source;
    • Review of the result(s) of each unique test;
    • Ordering of each unique test
  • Category 2 (Assessment Requiring an Independent Historian(s)): 
• Risk of Complications and/or Morbidity or Mortality of Patient Management
  • Low risk of morbidity from additional diagnostic testing or treatment

Defining the Total Time for E/M

As mentioned before, some E/M codes allow you to determine which code applies based on how much time was spent on the date of the encounter. The total time includes both face-to-face and non-face-to-face time. 

Some examples of activities that would count towards the total time spent include: 

• Completing a medically appropriate evaluation
• Counseling a patient about their wound’s progress 
• Reviewing test results when preparing to see a patient, such as their glucose or iron levels
• Documenting clinical information in the EHR, such as the type of wound and its current stage in the healing process 

Compared to MDM, it might seem that reporting E/M service codes using time spent is much easier. However, just like MDM, there are multiple definitions and rules that practitioners should be aware of. For instance, travel doesn’t count towards time spent on patient care, so it’s worth reading the E&M guidelines to know for sure what tasks are included. 

Examples of E&M Codes Based on MDM or Time Spent

At this point, it may be helpful to review some E&M codes and see firsthand how MDM and total time spent are applied. The following codes and their descriptions are from the New Patient subcategory of the Office or Other Outpatient Services category.

• 99202: The visit involves straightforward medical decision making, and/or the provider spends 15 or more minutes of total time on the encounter on a single date.
• 99203: The visit involves a low level of medical decision making, and/or the provider spends 30 or more minutes of total time on the encounter on a single date.
• 99204: The visit involves a moderate level of medical decision making, and/or the provider spends 45 or more minutes of total time on the encounter on a single date.
• 99205: The visit involves a high level of medical decision making, and/or the provider spends 60 or more minutes of total time on the encounter on a single date.

We’ve underlined the MDM and total time in each of the examples above so you can see what that code entails and why it might be selected. 

The Role of Documentation in E/M Coding 

You might be thinking, why would a wound care practitioner need to know how E/M codes work? After all, aren’t medical billers and coders the ones who handle the codes? While it’s true that their role involves coding services, coders can’t do so properly without accurate and detailed documentation from the provider. 

Why Accurate Documentation Matters

Although your primary job is healing patients, what and how you document also holds weight. Providing on-target documentation:    

• Maintains proper patient records. E/M codes support continuity of care, as they are based on what’s been documented in a patient’s record. If wound care providers use an incorrect code, it may result in denied or delayed treatment, affect future care decisions, and have other consequences. 
• Decreases the risk of compliance issues. Healthcare companies that don’t comply with coding guidelines and payer rules may face significant legal and regulatory consequences, including fines and penalties. 
• Encourages high-quality patient care. When used appropriately, E&M CPT codes can accurately reflect the complexity of care and encourage comprehensive care management. As depicted earlier, some codes reflect that more time was used, and those codes have higher reimbursements. This helps prevent providers from rushing through appointments and potentially missing critical details. 
• Promotes financial stability. Inaccurate coding can result in claim denials, under- or overbilling, audits, and other adverse consequences. When done correctly, it should result in timely and appropriate compensation. 
• Improves data quality. Proper documentation translates to E & M codes that enable us to collect data that reveals helpful insights, such as disease outbreaks. 
• Boosts workflow efficiency. When wound care providers properly document, it allows medical coders to apply the correct E/M codes the first time around. This, in turn, should lead to smoother workflows free of rejections, resulting in fewer instances of rework.

Best Practices for Evaluation and Management (E/M) Coding 

You now know what E&M codes are and why they’re important, but how do you go about applying the right ones? Here’s what we suggest to help your wound care practice remain compliant, maximize reimbursements, and improve patient care.

• Conduct Internal Audits and Improve: Make a point to perform regular audits of your company’s wound care documentation and billing practices. Afterward, revise processes and implement improvements in areas where you’ve identified gaps.  
• Monitor Changes: Stay on top of CPT code updates, payer changes, and billing regulations so you’re aware of how to remain compliant.
  • In the near future, we’ll likely see new CPT codes that take into account the work artificial intelligence completes.  
• Ongoing Education and Training: Conduct workshops, webinars, and seminars that provide your healthcare staff with the knowledge and training needed to understand documentation requirements. 
• Invest in Technology: Trying to keep up with regulatory changes and updated E/M codes doesn’t have to mean more work for your staff. A robust wound care EHR could make creating defensible documentation and applying proper E&M codes seamless. In fact, the right EHR could reduce your staff’s workload and boost your bottom line thanks to better reimbursements. 

The E&M Code Refresher for Wound Care Providers 

As you can see, E&M codes are pretty important, and they’re worth getting familiar with. They not only affect the quality, safety, and continuity of your patient’s care but also the types of reimbursement you receive. Failing to understand how they work could mean you’re leaving money on the table for the thorough work you do and/or jeopardizing patient care by under- or over-reporting.  

You and your team can refer to this E/M code refresher when you’re feeling unsure about what they are, why they’re important, and what you can do to apply the right ones. Be sure to also stay on top of updates from the AMA, AAPA, CMS, and more, so you’re aware of any updates and remain in compliance.