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5.3 Coding Evaluation and Management Services. 5-12. E/M Codes Cover physicians’ services performed to determine the optimum course for patient care New or established patient Place of service Referral Consultation

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5 3 coding evaluation and management services
5.3 Coding Evaluation and Management Services

5-12

E/M Codes

  • Cover physicians’ services performed to determine the optimum course for patient care
    • New or established patient
    • Place of service
    • Referral
    • Consultation
      • Remember the three Rs of consults: request opinion, render service, report back.
      • Medicare does not pay consult codes.
    • Level of service
      • extent of the patient history taken
      • extent of the examination conducted
      • complexity of the medical decision making
5 3 coding evaluation and management services cont
5.3 Coding Evaluation and Management Services Cont.

5-13

Eight Steps for E/M Code Assignment

  • Determine the category and subcategory of service based on the place of service and the patient’s status.
  • Determine the extent of the history that is documented.
    • History of Present Illness (HPI)
    • Review of Systems (ROS)
    • Past Medical History (PMH)
    • Family History (FH)
    • Social History (SH)
  • Determine the extent of the examination that is documented.
5 3 coding evaluation and management services cont1
5.3 Coding Evaluation and Management Services Cont.

5-14

Eight Steps for E/M Code Assignment Cont.

  • Determine the complexity of medical decision making that is documented.
  • Analyze the requirements to report the service level.
  • Verify the service level based on the nature of the presenting problem, time, counseling, and care coordination.
  • Verify that the documentation is complete.
  • Assign the code.
5 3 coding evaluation and management services cont2
5.3 Coding Evaluation and Management Services Cont.

5-15

Reporting E/M Codes on Claims

  • documentation guidelines for evaluation and management
  • office and hospital services
  • emergency department services
  • preventive medicine services