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Billing for E & M Codes

Medical billing and coding is an important part of the healthcare business. It is not enough to just accurately diagnose and treat an illness; you also need to accurately document, code and bill for the services provided. Non-familiarity with the rules and codes leads to under billing for the services provided. While it is possible that you may be underpaid for the services; it is also possible that your claims may be denied.

E & M Codes

E & M stands for ‘evaluation and management‘. E & M codes are the current procedural terminology (CPT) codes that describe patient – physician encounter. E/M codes are numeric and consist of five digits. Selecting the correct E/M code depends on the accuracy of the documentation provided. While precise documentation helps healthcare providers to evaluate and plan the line of treatment, it is also required by healthcare payers to ensure that the service provided is within the ambit of the patient’s insurance coverage. E/M services are documented based on three key components – History, Physical examination and Medical decision making. Unless the healthcare provider is coding based on ‘time’; these three key components are enough to satisfy E/M documentation requirements.

The CMS along with the AMA have developed the E/M guidelines – a set of rules that dictate the documentation required for each E/M code. The first version of the guideline was released in 1995 and the second and last in 1997. Both the versions are nearly identical in context to the history and medical decision making. However, there are substantial differences in the documentation required for the key component of physical examination. Healthcare providers have to select between the two versions of the E/M guidelines in their documentation of an E/M encounter.

Billing for an E/M service requires the selection of the CPT code that best represents the type of patient, the place/setting of the encounter and the level of service performed. Patients are identified as either new (one who has not received any professional service from the healthcare provider within the last three years) or established (one who has received professional service from the healthcare provider within the previous three years).

The place/setting of the physician-patient encounter could be an office or outpatient setting, a hospital inpatient, an emergency department, or a nursing facility. E/M services are defined into different categories and levels. While the three key components of E/M services provided are history, physical examination and medical decision making, an exception to this rule is encounters relating to counseling and/or coordination of care. As a thumb rule, the higher the complexity of the encounter, the higher the level of code used.

Given below are the CPT codes for E/M services:

99201-99499                Evaluation and Management Services

99201-99215                Office or Other Outpatient Services

99217-99226                Hospital Observation Services

99221-99239                Hospital Inpatient Services

99241-99255                Consultation Services

99281-99288                Emergency Department Services

99291-99292                Critical Care Services

99304-99318                Nursing Facility Services

99324-99337                Domiciliary, Rest Home (eg, Boarding Home), or Custodial Care Services

99339-99340                Domiciliary, Rest Home, or Home Care Plan Oversight Services

99341-99350                Home Services

99354-99416                Prolonged Services

99366-99368                Case Management Services

99374-99380                Care Plan Oversight Services

99381-99429                Preventive Medicine Services

99441-99449                Non-Face-to-Face Services

99450-99456                Special Evaluation and Management Services

99460-99463                Newborn Care Services

99464-99465                Delivery/Birthing Room Attendance and Resuscitation Services

99466-99486                Inpatient Neonatal Intensive Care Services and Pediatric and Neonatal Critical Care Services

99483-99484                Cognitive Assessment and Care Plan Services

99484-99484                General Behavioral Health Integration Care Management

99487-99490                Care Management Evaluation and Management Services

99492-99494                Psychiatric Collaborative Care Management Services

99495-99496                Transitional Care Evaluation and Management Services

99497-99498                Advance Care Planning Evaluation and Management Services

99499-99499                Other Evaluation and Management Services

MedConverge

To accurately bill the healthcare payer for the services provided, it is important that your documentation is concise and clear, the correct codes are selected that best reflect the services provided. Our certified coders review your documentation before selecting the correct and precise code to ensure that you are not short changed for the services provided.


References

  1. CPT Code Lookup. (2018). Retrieved September 12, 2018, from www.supercoder.com: https://www.supercoder.com/cpt-codes-range/2869
  2. (2018). Retrieved September 12, 2018, from www.emuniversity.com: https://emuniversity.com/Definitions.html
  3. Evaluation and Management Services. (2017, August). Retrieved September 12, 2018, from www.cms.gov: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf
  4. Hill, E. (2011, Sept-Oct). E/M Coding and the Documentation Guidelines: Putting It All Together. Retrieved September 12, 2018, from www.aafp.org: https://www.aafp.org/fpm/2011/0900/p33.html

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