Evaluation Management, commonly referred to as E&M, is known in medical clinics as the office CPT code that’s assigned to each patient visit. These codes range from level one to five and can be broken into two different categories: new and established. However, determining the code assignment is more complex than just using gut instinct – codes are actually assigned by using an intricate algorithm that takes into consideration the 3 components of the visit: the history, the exam and the medical decision-making.
Don’t worry, I’ll break down E&M codes, how they’re used and their history in the video below!
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So, what I’m going to talk to you today about is E/M. No, not M&M, E/M. Do you know what it means and its significance? For healthcare providers, the two letters, E and M are as important as M&Ms are to Mars, the company that produces them. Why, you say? It all comes down to revenue. E/M stands for Evaluation & Management. For medical clinics, this is the office visit CPT code assigned to each patient visit. These codes range from a Level 1 to a Level 5, with 5 being the highest risk, resulting in the highest revenue.
The codes are broken up into two different categories: New & Established. As an example for new patients coming into a physician’s office, these codes would range from a Level 99201 to 99205. Whereas, an established patient would have a code of 99211 all the way up to 99215 assigned.
Determining the code assignment is not as easy as figuring out how much time the provider spent with the patient, or just going with your gut instinct. The codes are assigned using an intricate algorithm that takes into consideration the three components of the visit: the History, the Exam, and the Medical Decision Making. The algorithm is based on a point system, then when added up in each of the sections of the History, Exam, and Medical Decision Making, will guide you to the E/M code that can be assigned. However, the overall arching code should be based on Medical Decision Making alone.
Now, to make this algorithm even more interesting, there are two sets of codes, 95 and 97. What? Two, you say? Yes, there are two. So how did this all begin? E/M codes were not used until 1992, when the American Medical Association, or the AMA, released them. However, they provided little to no training on how to use the new code set. Because of the extremely high error rate, CMS or the Centers for Medicare Services, stepped in and provided a guide to assist providers in determining their levels of service.
Initially released as the 1995 Documentation Guidelines for Evaluation and Management Services, CMS soon realized that providers who perform very specific exams, as well as specialists, suffered greatly, so the 1997 guidelines were publicized.
The main difference in the two sets is the exam portion of the calculation. For example, in the 1995 guidelines, a physician can document an entire organ system as normal and receive just one point for that. Whereas, the 1997 guidelines, require certain bullets within each exam be documented to receive credit for that exam. For 1995, indicating that you examined the musculoskeletal organ system gives you credit in that area versus 1997, which would require an examination of gait and station, assessment of the range of motion, and assessment of stability.
For providers that see patients for a variety of illnesses or injuries, 1995 guidelines would be better suited, while organ system-specific cases would be more suited for 1997 guidelines.
Now, you don’t have to decide as a practice which guidelines you’ll adopt for every patient. The guidelines give you the flexibility of deciding which code set do you want to use per patient. So, as an example, for patient A, who came in for an eye injury, the 1997 guidelines would provide you with a higher level of service, so you can choose to adopt that in that specific case. Then we have patient B that comes in for an illness, where multiple systems may be examined. In that case, 1995 guidelines would be more appropriate. So really you can toggle back and forth from patient-to-patient, but what you can’t do is to use the 95 and the 97 guidelines in various areas on the same patient.
So as you know, most payers follow these guidelines; however, there are the exceptions, of course. For those that don’t follow those guidelines, the details will be outlined in the contract that you signed with that particular payer. So you’ll need to refer to that document when billing out for those types of services. For all others, it’s important to know the guidelines themselves, and/or have qualified staff to review the E/M levels prior to claim submission. Otherwise, you’ll see insurance carriers down-coding your visits. As well, conduct periodic audits to ensure documentation, medical necessity to support that level of service.
So watch for my next segment, when I’m actually going to break down the algorithm of the E/M levels individually. Thank you.