E&M Codes

E&M Codes – Evaluation and Management Codes

We can select the appropriate level of E&M codes based on the following:

• Key Components (New Patient – 3/3 and Established Patient –  2/3)
• Based on time of counseling

Key components of E&M codes

The 3 important key components of E&M codes are:

1. History of the Patient
2. Physical Exam
3. Medical Decision Making

Based on these key components, we assign the E&M codes. Each component expressed with different terms to select the appropriate E&M code:

1. History of the patient:

• Problem focused
• Extended problem focused
• Detailed
• Comprehensive

 

2. Physical Exam

• Problem focused
• Extended problem focused
• Detailed
• Comprehensive

 

3. Medical Decision Making

• Straight Forward
• Low Complexity
• Moderate Complexity
• Higher Complexity

When selecting the E&M codes, if all the 3 key components are meeting or matching then we can select the appropriate E&M Code.

How to select the level of E&M codes for New Patient?

Let us see with examples on how to select the appropriate level for New Patient E&M codes (3/3):

Assume new patient visits the doctor office for treatment.

Example 1:

After reviewing the medical records assume the following 3 key components are documented:

1. History (H) – Problem Focused
2. Physical Exam (PE) – Problem Focused
3. Medical Decision Making (MDM) – Straight Forward

PF – 99201

PF – 99201

SF – 99201/99202

If it’s a new patient 3/3 key components should meet. In the above example all the 3 key components falls under 99201, hence we can report 99201 E&M code.

Note: If counseling leads more than 50 percent, than time shall be considered to qualify for the specific level of E&M code.

 

Example 2:

Suppose if all the 3 key components are not matching, then how to select the appropriate E&M code.

After reviewing the medical records, now assume the following 3 key components are documented:

1. History (H) – Detailed
2. Physical Exam (PE) – Extended Problem Focused(EPF)
3. Medical Decision Making (MDM) – Moderate Complexity(MC)

In the above example the 3 key components are not at the same level

Detailed – 99203

EPF – 99202

MC – 99204

If it’s a new patient visit, when the levels are not meeting, then code with the lowest one.

In this case, we have to select the lowest CPT code that is 99202.

Note: If counseling dominates more than 50%, than time shall be considered the key factor to qualify for the particular level of E&M service.

 

Example 3:

Consider one more example with same scenario but with different key components,

 

1. History (H) – Detailed
2. Physical Exam (PE) – Extended Problem Focused(EPF)
3. Medical Decision Making (MDM) – Low Complexity(LC)

Detailed – 99203

EPF – 99202

Low Complexity – 99203

In this 2 is matching, but still we code with the lowest one that is 99202.

Note: If counseling dominates more than 50%, than time shall be considered the key factor to qualify for the particular level of E&M service.

 

Example 4:

1. History (H) – Extended Problem Focused(EPF)
2. Physical Exam (PE) – Extended Problem Focused(EPF)
3. Medical Decision Making (MDM) – Straight Forward(SF)

EPF – 99202

EPF – 99202

SF – 99201/99202

In this case the CPT 99202, all the 3 key components are meeting. Hence we code with E&M code 99202.

Note: If counseling dominates more than 50%, than time shall be considered the key factor to qualify for the particular level of E&M service.

 

How to select the E&M codes of Established patient?

Now let us see with examples on how to select the appropriate level for Established Patient E&M codes (2/3):

Now assume Established patient visits the doctor office for treatment.

Example 1:

1. History (H) – Problem Focused(PF)
2. Physical Exam (PE) – Extended Problem Focused(EPF)
3. Medical Decision Making (MDM) – Moderate Complexity(MC)

PF – 99212

EPF – 99213

MC – 99214

All three key components are at different level. If it is an established patient, we will select the 2^nd lowest E&M code by dropping the 1^st lowest E&M code.

In the above example 1^st lowest E&M code is CPT 99212 and second lowest E&M code is CPT 99213. Hence as per guidelines we drop the 1^st lowest code and select the second lowest code that is CPT 99213.

Note: If counseling dominates more than 50%, than time shall be considered the key factor to qualify for the particular level of E&M service.

Example 2:

1. History (H) – Extended Problem Focused(EPF)
2. Physical Exam (PE) – Extended Problem Focused(EPF)
3. Medical Decision Making (MDM) – Moderate Complexity(MC)

EPF – 99213

EPF – 99213

MC – 99214

Answer is CPT 99213

Example 3:

1. History (H) – Comprehensive
2. Physical Exam (PE) – Detailed
3. Medical Decision Making (MDM) – Low Complexity(LC)

Comprehensive – 99215

Detailed – 99214

Low Complexity – 99213

Answer is CPT 99214

Note: If counseling dominates more than 50%, than time shall be considered the key factor to qualify for the particular level of E&M service.

 

Based on the Place of Service (POS) – place where the service provided, we are going to select the E&M codes.

Some of the important E&M codes based on place of service which are frequently used is listed as follows:

1. Office visit/Out Patient E&M Codes
2. New patient E&M codes (3/3)

• 99201
• 99202
• 99203
• 99204
• 99205

 

1. Established Patient E&M Codes (2/3)

• 99211
• 99212
• 99213
• 99214
• 99215

 

2. Hospital Inpatient E&M Codes
3. Initial Hospital Care E&M codes (3/3)

• 99221
• 99222
• 99223

 

1. Subsequent Hospital Care E&M codes (2/3)

• 99231
• 99232
• 99233

 

1. Hospital Discharge Services E&M Codes

• 99238
• 99239

 

3. Observation or Inpatient care E&M Codes
4. Same day admission & discharge E&M codes(3/3)

• 99234
• 99235
• 99236

 

1. Different day admission & discharge E&M codes
2. Intial Observation care(3/3)

• 99218
• 99219
• 99220

 

1. Subsequent Observation Care(2/3)

• 99224
• 99225
• 99226

 

• Observation care Discharge Services
• 99217

 

4. Consultation E&M Codes
5. Outpatient Consultation codes (3/3)

• 99241
• 99242
• 99243
• 99244
• 99245

 

1. Inpatient Consultation codes (3/3)

• 99251
• 99252
• 99253
• 99254
• 99255

 

5. Nursing Facility Services
6. Initial Nursing Facility Care(3/3)

• 99304
• 99305
• 99306

 

1. Subsequent Nursing Facility Care(2/3)

• 99307
• 99308
• 99309

 

1. Nursing Facility Discharge Services

• 99315
• 99316

 

1. Other Nursing Facility Services(3/3)

• 99318

 

6. Domiciliary, Rest home, or Custodial care services
7. New patient(3/3)

• 99324
• 99325
• 99326
• 99327
• 99328

 

1. Established patient(2/3)

• 99334
• 99335
• 99336
• 99337

 

7. Home Services
8. New patient(3/3)

• 99341
• 99342
• 99343
• 99344
• 99345

 

1. Established patient(2/3)

• 99347
• 99348
• 99349
• 99350

 

8. Prolonged Services E&M Codes (Add on codes)

• +99354
• +99355
• +99356
• +99357