Question

1. What type of physician uses Evaluation and management codes? 2. How is the correct level of E/M code found? 3. How do the key components and contributing factors play a role on choosing the correct E/M code?

Answer 1

Evaluation and management codes the physician uses are category of Current Procedural Terminology (CPT) code. The code sets to bill for E/M services are organized into various categories and levels. In common, the more complex the visit, the higher the level of code you may bill within the appropriate category. To bill any code, the services furnished must meet the definition of the code. You must ensure that the codes selected reflect the services furnished.

The levels of E/M services are based on four types of examination: Problem Focused; Expanded Problem Focused; Detailed and Comprehensive.

The three key components when choosing the correct level of E/M services provided are history, examination, and medical decision making.

History: The Elements Required for Each Type of History table depicts the elements required for each type of history. For example, a problem focused history requires documentation of the chief complaint (CC) and a brief history of present illness (HPI), while a detailed history requires the documentation of a CC, an extended HPI, plus an extended review of systems (ROS), and pertinent past, family, and/or social history (PFSH).

Examination: An examination may involve several organ systems or a single organ system. The type and extent of the examination performed is based on clinical judgment, the patient’s history, and nature of the presenting problem(s).

Medical decision making: Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option.