Evaluation & Management (E/M) - Articles

Three Things To Know When Reporting Prolonged Services in 2023
January 31st, 2023 - Aimee Wilcox
The Evaluation and Management (E/M) changes made in 2021 and again in 2023 brought about new CPT codes and guidelines for reporting prolonged services. Just as Medicare disagreed with CPT in the manner in which prolonged service times should be calculated, they did so again with the new 2023 changes. Here are three things you should know when reporting prolonged services for all E/M services.
E/M Transformations and Clarifications Eff January, 1 2023
January 10th, 2023 - Chris Woolstenhulme
Pay close attention to the new code description changes when coding E/M in 2023, the changes keep coming. Several codes have been consolidated, revised, or deleted. Learn what to look for in this article.

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Changes to the 2023 Evaluation & Management (E/M) Definitions for Acute Conditions
November 8th, 2022 - Aimee Wilcox
On January 1, 2023 the Evaluation and Management (E/M) Guidelines will change again but this time with a focus on all other E/M categories. These changes are very similar to the changes that took place in 2021, with scoring of the E/M service level being determined by MDM or time. The original 2021 E/M diagnosis severity definitions changed again, after implementation and with the new changes in 2023, new diagnosis definitions have been added, warranting another look at what is new and how to interpret the changes.
How Does the Definition of "Problem Assessed" Change in the 2023 E/M Guideline Updates?
November 1st, 2022 - Aimee Wilcox
The 2023 Evaluation and Management changes have been published and efforts are ongoing to educate coders and provider organizations on the guideline and code description changes that will impact professional coding in the facility setting. These changes required a significant revision to the guidelines and definitions of the various levels of complexity associated with the Number and Complexity of "Problems Addressed" during an encounter, which is the first element of medical decision making (MDM) and the following explanations and examples should provide a greater understanding of the changes headed our way in January.
2023 Evaluation & Management Updates Free Webinar
October 24th, 2022 - Aimee Wilcox
Congratulations on a successful 2021 implementation of the Evaluation and Management (E/M) changes! That was a big change, but now an even bigger change is headed your way for inpatient and all other E/M categories. How great is it that almost all of the E/M categories will now be scored based on medical decision making (MDM) or total provider time? Standardized scoring and one set of E/M guidelines has the potential of bringing about a change or improvement of provider fatigue due to over regulation and documentation burden.
Significant Changes to Emergency Department E/M Reporting Coming in 2023
October 24th, 2022 - Aimee Wilcox
In just a few short months, major revisions to the remaining Evaluation and Management categories in the Current Procedural Terminology (CPT) code book will go into effect. How many of these changes will affect your organization and how ready are you for them? While the changes to the remaining E/M categories will closely resemble the 2021 changes to the E/M Office and Other Outpatient (99202-99215) codes, there are some major differences that need to be carefully reviewed, such as how E/M will change for the Emergency Department services.
AMA Announces Big Changes in 2023 to Remaining Evaluation & Management Coding
September 15th, 2022 - Aimee Wilcox
The American Medical Association's CPT Editorial Panel has published the newest updates to the 2023 CPT codebook, which include the second biggest changes to Evaluation and Management (E/M) coding in 30 years - affecting all remaining E/M code categories. Many sections have been completely deleted or merged into another set of codes, and time thresholds are completely different.
Considering the Impact of Diagnosis Codes in the E/M Encounter
March 29th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Social Determinants of Health (SDoH) can impact the level of MDM and overall E/M service reported for codes 99202-99215. With new SDoH codes added annually to the ICD-10-CM code set and health equity as a CMS goal, it is important to identify the role of proper diagnosis coding in determining the level of E/M service.
Important Changes to Shared/Split Services
June 16th, 2021 - Aimee Wilcox CPMA, CCS-P, CST, MA, MT and Wyn Staheli, Director of Content Research
Reporting of split (or shared) services has always been wrought with the potential for incorrect reporting when the fundamental principles of the service are not understood. A recent CMS publication about these services further complicates the matter.
Understanding Non-face-to-face Prolonged Services (99358-99359) in 2021
June 3rd, 2021 - Aimee Wilcox CPMA, CCS-P, CST, MA, MT and Wyn Staheli, Director of Content Research
Due to the extensive changes in office or other outpatient services (99202-99215), there are many questions which still need to be answered, one of which is related to the prolonged services without face-to-face contact. This article explores the question regarding the appropriate use of codes 99358/99359 and how to report it.
Evaluation & Management (E/M) Webinar Q/A
April 1st, 2021 - Aimee Wilcox CPMA, CCS-P, CST, MA, MT and Wyn Staheli, Director of Content Research
Find answers to some questions asked by attendees of our recent webinar regarding the changes released by the AMA in their March 9, 2021 Errata and Technical Corrections document in relation to Evaluation & Management (E/M).
How Reporting E/M Based on Time May Lose Money
March 18th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Just like math teachers who require students to show their work so they can see how the student reached their answer, providers are also required to "show their work" through the documentation process in the medical record. By the time a provider has reviewed the patient's subjective complaints (i.e., patient's ...
CDT and CPT - The Same but Different!
December 8th, 2020 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
Reporting a CPT code for an evaluation of a patient is based on time and if the patient is a new or established patient. Evaluation and Management codes are different than other codes, it is important to understand how they are used, prior to 2021 they were based on a ...
Impact of 2021 Proposed Medicare Fee Schedule on Chiropractic Offices
August 7th, 2020 - Wyn Staheli, Director of Research
On August 3, 2020, the proposed Medicare Physician Fee Schedule for 2021 was released. This 1,355 page document includes some sweeping changes to the Medicare program. There are a few items in particular which should be noted by chiropractic offices.
More Telehealth Changes Announced by CMS
April 2nd, 2020 - Wyn Staheli, Director of Research
On March 31, 2020, CMS announced further changes to their telehealth program in response to this unprecedented public health emergency (PHE). See this article for further information as well as references & links to CMS information
Q/A: Can Chiropractors Bill 99211?
January 14th, 2020 - Wyn Staheli, Director of Research
Can chiropractic offices bill code 99211? Technically it can be used by chiropractors, but in most instances, it is discouraged. Considering that 99211 is a low complexity examination for an established patient, this code is not really made for the physician to use. In fact, in 2021, changes are coming for this code...
Billing for Telemedicine in Chiropractic
January 14th, 2020 - Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP
Many large private payers recognize the potential cost savings and improved health outcomes that telemedicine can help achieve, therefore they are often willing to cover it. While there are several considerations, there could be certain circumstances where telemedicine might apply to chiropractic care.
Eliminating Consultation Codes?
October 10th, 2019 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
There are a few payers that have joined with CMS in discontinuing payment for consultation codes. Most recently, Cigna stated that, as of October 19, 2019, they will implement a new policy to deny the following consultation codes: 99241, 99242, 99243, 99244, 99245, 99251, 99252, 99253, 99254 and 99255. United Healthcare announced they ...
Q/A: How Do I Bill a House Call?
September 30th, 2019 - Wyn Staheli, Director of Research
Question If a provider makes a house call to/for a patient, is there a way that it is represented on the claim form? A modifier, or something else? Answer Modifiers are not used to identify that a service was performed in the patient's home. However, other modifier rules must be followed (e.g., modifier GP ...
E-Health is a Big Deal in 2020
September 16th, 2019 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
The new 2020 CPT codes are on the way! We are going to see 248 new codes, 71 deletions, and 75 revisions. Health monitoring and e-visits are getting attention; 6 new codes play a vital part in patients taking a part in their care from their own home. New patient-initiated ...
CMS Proposes to Reverse E/M Stance to Align with AMA Revisions
August 6th, 2019 - Wyn Staheli, Director of Research
On July 29, 2019, CMS released their proposed rule for the Medicare Physician Fee Schedule for 2020. Last year’s final rule “finalized the assignment of a single payment rate for levels 2 through 4 office/outpatient E/M visits beginning in CY 2021.” It also changed some of the documentation requirements (e.g., ...
A United Approach
June 14th, 2019 - Namas
A United Approach As auditors, we all have a different perspective when evaluating documentation. It would be unreasonable to think that we all view things the same way. In my opinion, differing perspectives are what makes a great team because you can coalesce on a particular chart, work it through and ...
What Medical Necessity Tools Does Find-A-Code Offer?
June 13th, 2019 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Find-A-Code is a great resource for individuals working in all aspects of healthcare, from providers and ancillary staff to the attorneys and payers who assess and critique the documentation supporting the services performed. When recently asked what tools Find-A-Code has to help support medical necessity, our response was, "We provide many resources ...
Noting "Noncontributory" for Past Medical, Family, Social History - Is It Acceptable?
May 29th, 2019 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Is "noncontributory" really an unacceptable word to describe a patient whose family history doesn't have any bearing on the condition being evaluated and treated today?
What to Look for When Auditing Smoking Cessation Services
May 24th, 2019 - NAMAS
What to Look for When Auditing Smoking Cessation Services
CPT Announces 2021 E/M Changes
April 23rd, 2019 - Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT
In 2018, Medicare announced their plans for revamping the Evaluation and Management coding structure and was met with a rapid response from the medical community, including the AMA and many other organizations. As a result, the Medicare changes implemented in 2019 were mostly documentation-related changes that generally benefited providers but were not ...
What is Medical Necessity and How Does Documentation Support It?
April 23rd, 2019 - Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT
We recently fielded the question, “What is medical necessity and how do I know if it's been met?" The AMA defines medical necessity as: It is important to understand that while the AMA provides general guidance on what they consider medically necessary services, these particular coding guidelines are generic and may be ...
The Impact of Medical Necessity on High Level E/M Services
March 21st, 2019 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
I was recently asked the question, "Does 99233 require documentation of a past medical, family, and/or social history (PFSH)?" The quick answer is, "it depends." Code 99233 has the following minimal component requirement: Subsequent inpatient E/M encounters can meet the code level requirement either by component scoring & medical necessity or time & medical necessity. ...
Take the Stress out of Leveling Using our E/M Calculator
January 17th, 2019 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Our E/M Calculator takes the stress out of leveling Evaluation and Management codes. This tool can be used by auditors, as well as coders and students learning E/M coding. Calculate based on Time or Components. The exam portion lets you chose either 95, 97 Guidelines or both.  Included with our Professional and Facility Subscription!  ...
Billing 99211 Its not a freebie
November 9th, 2018 - BC Advantage
It seems like a simple code to bill, but CPT 99211 (established patient office visit) is by no means a freebie when it comes to documentation and compliance. This lowest level office visit code is sometimes called a "nurse visit" because CPT does not require that a physician be present...
Are you Ready for CMS' 2019 Medicare Physician Fee Schedule Final Rule?
November 7th, 2018 - Wyn Staheli, Director of Research
The waiting is over, the Final Rule for CMS' 2019 Medicare Physician Fee Schedule (MPFS) is available - all 2,379 pages for those looking for a little light reading. As anticipated, there are some pretty significant changes. Most of us were carefully watching the proposed changes to the Evaluation and ...
Prolonged Services Its Not Just About Time
October 5th, 2018 - BC Advantage
Time, as it applies to E/M codes, has often been viewed as an "if/then" proposition. "If" the documentation shows that a majority of the encounter was based on counseling and/or coordination of care, "then" we choose the highest level of service based on the total time of the encounter. However, a ...
When to Use Modifier 25 and Modifier 57 on Physician Claims
October 1st, 2018 - BC Advantage
The biggest thing modifiers 25 and 57 have in common is that they both assert that the E/M service should be payable based on documentation within the record showing the procedure should not be bundled into the E/M. After that, the similarities end, and it is important to know the...
The Potential Impacts of a Flat Rate EM Reimbursement on our Industry
September 26th, 2018 - BC Advantage
The proposed E&M changes by CMS would decrease provider administrative work burden by, per CMS, 51 hours a year; however, how will reducing documentation requirements truly affect the professionals of the healthcare industry? First, let’s discuss the 30,000-foot overview of the most impactful E&M changes—which is the change to the...
BREAKING NEWS: CMS Proposes to Change E&M Coding
August 15th, 2018 - Christine Taxin
On July 16th 2018, anyone subscribed to the CMS Quality Payment Program received an e-mail containing a letter to doctors from Seem Verma, Administrator of the Centers for Medicare and Medicaid Services (CMS). There are some widespread changes proposed in this letter of which you need to be aware. Where ...
When Medical Necessity and Medical Decision Making Don't Match
August 3rd, 2018 - BC Advantage
As coders and auditors, we are taught the documentation guidelines on how to determine medical decision making. However, Medicare is clear that medical necessity is what determines the overall payment. In order to know what to do when medical necessity and medical decision making do not line up, you must...
Attention Providers - Please Make Time to Read this Letter
July 17th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
In an effort to show CMS is committed to changing the rules to accommodate their providers CMS released a letter to Doctors of Medicare Beneficiaries. The letter offers encouragement and a promise to reduce the burden of unnecessary rules and requirements. The letter states “President Trump has made it clear that ...
CMS Proposed New E/M Codes for Podiatry
July 16th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
According to CMS changes are coming for E/M codes.  A recent proposal from CMS stated: "The E/M visit code set is outdated and needs to be revised and revalued." Since podiatry tends to furnish a lower level of E/M visits, CMS is proposing new G-codes to report E/M office/outpatient visits. The proposed ...
Auditing Therapy Evaluation Codes - Not So Quick!
June 4th, 2018 - Nancy J Beckley, MS, MBA, CHC
New evaluation codes for physical therapy (PT) and occupational therapy (OT) codes were made effective 1/1/2017. Three new physical therapy evaluation codes replaced 97001, and three new occupational evaluation codes replaced 97003. Chart 1 - Short Code Descriptors The PT and OT reevaluation codes remain the same but were...
Webinar: Basic E&M Avoiding Common Errors
May 1st, 2018 - Find-A-Code
Join us for AAPC CEU approved Education and Outreach with Noridian BASIC E AND M AVOIDING COMMON ERRORS Start Date: 5/15/18 Duration: 11:00 AM – 12:00 PM - Pacific Daylight Time Type: Web-based Workshop Register Now: https://attendee.gotowebinar.com/register/7977003427311130113 Abstract: This presentation is designed to provide basic information on the billing and...
Documentation for Evaluation and Management (E/M) Services
March 26th, 2018 - Nicole, QCC
According to WPS, when billing or coding for E/M services you should follow a few guidelines. Documentation must support the level of service billed and the medical necessity for the level billed. Below are additional tips for services which commonly incur CERT error findings for insufficient documentation. Critical Care Visits Clear indication of patient ...
Q/A: Why is Code 99080 Being Denied when Billed with an E/M Service?
March 21st, 2018 - Wyn Staheli, Director of Research
In order to understand and answer the question, "Why code 99080 is being denied when billed with an E/M Service, it is important to first review the requriements of selecting the appropriate level of Evaluation and Management service and how that relates to reporting a 99080 special report service. Continue reading for better understanding.
CPT Code for DOT exams
March 13th, 2018 - Wyn Staheli, Director of Research
Question: I have a provider that provides Department of Transportation (DOT) exams. I have found ICD-10 code Z02.4 (encounter for examination for drivers license) but I am unsure which CPT Code to use. Would I still use 99203 or 99204?
Consultation Codes Q/A
February 20th, 2018 - ChiroCode
Question Are there consultation codes that can be used for new and existing patients when a review of systems and detailed history is performed but no examination due to the patient's reluctance to make a decision to continue with the visit but has taken up 30-45 minutes of the doctors time?
Scoring & Reporting Your Audit Findings
February 2nd, 2018 - Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT
This week we had a great question posted to our online forum, and I thought it would be a nice thought- provoking question for our auditing and compliance tip of the week.
What's the definition of an Office Visit and Can I Bill it With a Chiropractic Treatment?
January 18th, 2018 - Brandy Brimhall, CPC CPCO CMCO CPMA QCC
What is the definition of Office Visit? Can It be billed with a Chiropractic Treatment? What about using code 99123 E&M code for office visits? Can we bill of office visits even though we are giving chiropractic care?
Should ROM Testing be Reported with Evaluation and Management Services?
January 9th, 2018 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT
Reporting the performance of range of motion testing (95851-95852) at the same encounter of an Evaluation and Management (EM) service, produces an NCCI edit resulting in payment for the EM service and denial of the ROM testing. Read the article to learn what other codes ROM testing is considered incidental to.
Auditing Medical Decision Making
November 3rd, 2017 - Grant Huang, CPC, CPMA
With CMS looking to gradually revise its E/M documentation requirements to reduce the burden and complexity they pose to providers, it's a great time to review the trickiest E/M component: medical decision making (MDM)....
CMS Proposes to Revise Evaluation & Management Guidelines
October 26th, 2017 - BC Advantage
According to the recently released 2018 Physician Fee Schedule Proposed Rule, published in the Federal Register, dated July 21, 2017, the Centers for Medicare & Medicaid Services (CMS) acknowledges that the current Evaluation and Management (E/M) documentation guidelines create an administrative burden and increased audit risk for providers. In response, ...
PFSH Documentation: Q and A
October 20th, 2017 - Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT
When coding an E/M visit in the emergency department, would you count all PFSH listed even if they don't pertain to the indication as to why the patient arrived?
New Policy from UnitedHealthcare
September 22nd, 2017 - Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA, CEMA
In the June 2017 UHC Network Bulletin, there was an article that addressed UHC's decision to no longer pay for consultation services.....
How to Properly Report Prolonged Evaluation and Management Services
September 13th, 2017 - Aimee Wilcox
Have you ever had a patient take more time with the provider than they were scheduled for? Do you understand which codes to report and the rules that govern them to allow for better reimbursement? Prolonged Service codes were created just for that reason but you must carefully follow the documentation ...
Auditing Prolonged Evaluation and Management Services
September 12th, 2017 - Aimee Wilcox
At times, there are patients who require prolonged face-to-face time with the provider to discuss or be counseled about their condition, plan of care, risks, complications, alternative therapies, or other medical issues. When E/M services go wild, taking significantly longer than the typical time associated with it, that direct face-to-face ...
2017 Physical Therapy Evaluation & Management Codes
September 1st, 2017 - Kathy Price, RHIT, CPC, CCS-P, CPMA
As you know, 2017 brought us new evaluation and management codes for physical and occupational therapy....
The Incredible Disappearing Consultation
August 18th, 2017 - J. Paul Spencer, CPC, COC
In January of 2010, CMS ceased payment of CPT codes for consultations (99241 through 99245 for outpatient, and 99251 through 99255 for inpatient).
Consultation or Transfer of Care, What are the Differences?
June 30th, 2017 - Dee MiMauro, CPC, COC, CPMA
According to 2017 Current Procedural Terminology (CPT), a Consultation is a type of E&M service provided by a physician at the request of another physician or other appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of ...
NGS Medicare Releases New Audit Tool
June 30th, 2017 - Liz Wilson, RHIT, CCS, CDIP, CPC, CRC, CEMC
Evaluation and Management (E/M) codes are defined by the AMA Current Procedural Terminology (CPT®) codebook and while they are the most commonly utilized CPT codes, their code descriptions have not changed in years.
E/M Table of Risk
March 29th, 2017 - Wyn Staheli
The final sub-component of Medical Decision Making is the Risk of Significant Complications, Morbidity and/or Mortality. The following is the official Evaluation and Management Table of Risk. The level is selected by choosing one element from three criteria (Presenting Problem, Diagnostic Procedures Ordered, and Management Options), with the highest level selected ...
Evaluation and Management Coding is Manageable
March 3rd, 2017 - Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP
As a chiropractor, we use E/M codes frequently, but not at every encounter, as do our medical counterparts. These are the CPT codes used to describe the work involved in figuring out what is wrong with a patient and creating a plan to manage them. One of my good friends, ...
Double Dipping in the History of the Evaluation and Management Note
March 3rd, 2017 - Aimee Wilcox, MA, CST, CCS-P, CPMA
There are many rules and guidelines a coder must be aware of when it comes to appropriately selecting an Evaluation and Management (EM) code and avoiding doubling dipping is one of them.  Double dipping occurs when the same information is used in more than one of the subcomponents of history. The subcomponents of history include: Chief Complaint ...
E/M 101
November 29th, 2016 - BC Advantage
E/M stands for "evaluation and management". E/M coding is the process by which provider-patient encounters are translated into five digit CPT codes to facilitate billing. CPT stands for "current procedural terminology." These are the numeric codes which are submitted to insurers for payment. Most billable procedures have their own CPT ...
Anesthesia and E/M services
July 29th, 2016 - Codapedia
Anesthesia services are billed using CPT® codes 00100-01999. These CPT® codes are cross-walked to surgical codes. The crosswalk is available from the American Society of Anesthesiologists at www.asahq.org. Each anesthesia code has a base unit assigned to it. The anesthetist also bills the number of time units, with a single...
Evaluation and Management Services
July 29th, 2016 - Codapedia
According to the CPT® book, E/M services are divided into categories and subcategories. Office services are divided into new and established patient visits. Consultations are divided into outpatient/office consults and inpatient consultations. The E/M services typically have three to five levels of services and these levels are not interchangeable from...
Subsequent hospital visits
December 29th, 2015 - Codapedia Editor
Hospital services are all defined by CPT® as per day codes, that is, all of the care provided to a hospitalized patient during the calendar day. If a physician (or that physician's covering partner of the same specialty) sees the patient a second time during the calendar day, a second visit is...
Family history--what counts
December 29th, 2015 - Codapedia Editor
The Documentation Guidelines describe family history as: a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk This family history is a review of the illness's, health status, and cause of death of close members of the patient's...
Modifiers in Postoperative Periods
December 29th, 2015 - Allison Singer, CPC
Modifiers in Postoperative Periods Introduction Documenting the events of a patient visit is not always the simplest and most straightforward of processes. Many variables affect which information must be included in order to report a procedure or service accurately. Global periods are one of...
Pre-op visits: True or False?
December 29th, 2015 - Codapedia Editor
Are the following statements true or false? • The PCP cannot be paid to do a pre-op assessment of a Medicare patient prior to surgery because of the new consult rules. • The surgeon can never be paid to do a pre-op visit if s/he is going to take the patient to surgery. • The...
Cloned E/M notes
December 29th, 2015 - Codapedia Editor
Have you ever read a physician office note and thought it was strangely familiar? Or, not just familiar but identical to another note? Well, Medicare contractors have noticed the same thing, and the Office of Inspector General has included this on their 2011 Work Plan. Medicare contractors have...
Subsequent nursing home visits
December 29th, 2015 - Codapedia Editor
Subsequent nursing facility visits are reported with codes 99307--99310. These codes are defined as per day codes, and do not have new and established patient divisions. There are also initial nursing facility codes, which only a physician may use. A physician or NPP may use the subsequent...
Coding Excisions and Wound Repairs
October 15th, 2015 - Allison Singer, CPC, CPMA
Chart audits frequently examine coding associated with lesion removals and wound repairs. In order to assign the appropriate procedure code, certain documentation must be included in the medical record, such as lesion type, excision size, wound repair, and location. Without these important details,...
99213 Established patient visit
October 15th, 2015 - Betsy Nicoletti
There are sample audited notes in resource section. 99213 is an established patient visit which requires 2 of 3 of the following components: An expanded, problem focused history, which is 1-3 HPI elements and 1 system in ROS reviewed An expanded, problem focused exam, which is 6 bullets from...
Evaluation and Management Services
July 27th, 2015 - Codapedia Editor
According to the CPT® book, E/M services are divided into categories and subcategories. Office services are divided into new and established patient visits. Consultations are divided into outpatient/office consults and inpatient consultations. The E/M services typically have three to five...
I had a wheezer in the office, can I bil a 99215?
July 27th, 2015 - Codapedia Editor
At a coding session at a recent Pri-Med conference a Pediatrician asked this question: "I had wheezer in the office, and he was in the office a long time. I examined him, we did pulxe oximetry measurements, which we never get paid for both before and after a nebulizer treatment. I was in and...
What counts as social history?
July 27th, 2015 - Codapedia Editor
The Documentation Guidelines say social history is: an age appropriate review of past and current activities. As auditors, we interpret this to include: smoking, alcohol and drug use living arrangements employment history school history support system, if relevant In...
Modifier 25
July 27th, 2015 - Codapedia Editor
Modifier 25: Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service. Refer to the CPT® book for the complete definition. Modifier 25 is appended to the E/M service, never to a procedure. The decision about whether to bill for...
Can we bill a low level E/M with every procedure?
June 1st, 2015 - Codapedia Editor
Can’t we bill a low level E/M with every procedure? No! Medicare says this: Per CCI (chapter 11, Letter R.): “The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E/M service. ...
Medical Necessity is not Medical Decision Making
June 1st, 2015 - Codapedia Editor
I can count on two consistent issues in coding audits. Doctors report that their patients are, in general, sicker than patients in other practices. Coders report that their physicians are, in general, worse documenters than physicians in other practices and select codes that are too high based on...
Observation versus inpatient status
June 1st, 2015 - Betsy Nicoletti
Physicians are often confused about whether to bill for observation status or inpatient status for patients admitted to the hospital. There are specific rules in the Medicare Claims Processing Manual, but sometimes the question is: what is the status of the patient? Commercial carriers have long...
How to research coding questions
June 1st, 2015 - Christina Benjamin
How to Research Answers to Coding Questions Perform a search of the discussion board or listserv website prior to posting a new question. For your search terms, include specific words such as the diagnostic statement or procedure statement or the specific code number or ...
Preventive medicine and office visit, same day
June 1st, 2015 - Codapedia Editor
Can I use modifier 25 on an E/M service on the same day as a preventive medicine exam Let’s review what a preventive medicine service is, in order to answer that question. Preventive medicine services are: • The description given by CPT® for “annual physicals” •...
Category of Code Selection
March 17th, 2015 - Codapedia Editor
Does anyone remember the good old days, when you didn't need to know the patient's insurance to select a category of code? Now, correct selection of an E/M category of code requires the clinician and coder to consider: Where the service was performed The status of the patient...
New Patient
March 17th, 2015 - Codapedia Editor
According to the American Medical Association’s CPT® book, a new patient is a patient who “has never received professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years. There is an excellent...
Past medical, family and social history
March 17th, 2015 - Codapedia Editor
Rules for documenting the past medical, family and social history in an E/M note
Preventive medicine service and office visit on the same day
January 30th, 2015 - Codapedia Editor
Modifier 25 for Preventive medicine service and office visits The CPT® book describes modifier 25 as the modifier to be used on an E/M service when "a Significant, Separately Identifiable Evaluation and Management Service” is performed by the same physician on the same day of the...
Don’t expect to see payment any time soon for ‘telephone consults’
October 15th, 2014 - Scott Kraft
Four new CPT® codes that got some attention when the 2014 CPT® changes were released late last year were a new E/M code series, 99446-99449, designed to be reported when a consulting provider offered a telephone or Internet E/M service that included a verbal and written report back to the...
CMS: Lot of errors billing psychotherapy services when E/M visit is involved
October 15th, 2014 - Scott Kraft
The Comprehensive Error Rate Testing (CERT) program Medicare uses to assess the accuracy of provider billing has uncovered a big source for mistakes – documentation problems when a patient is receiving psychotherapy services on the same date as an E/M encounter, according to CMS. There are...
Cloned documentation on OIG radar screen in 2014
May 23rd, 2014 - Scott Kraft
One of the areas where the OIG has its sights set in 2014 is on physician documentation. The OIG plans to review documentation of E/M services looking for what it describes as “documentation vulnerabilities.” Put more specifically, the OIG reports that Medicare Administrative...
Hospital discharge, nursing facility admit billable on same day by same provider in most instances
November 18th, 2013 - Scott Kraft
Medicare will typically pay for a hospital discharge service (billed with 99238-99239) and a nursing facility admission visit (99304-99306) when billed on the same date of service (DOS) by the same provider without the need for a modifier. As always, however, there are a couple of exceptions. The...
Mini Mental Status Exam
October 1st, 2013 - Betsy Nicoletti
There is no CPT® code for the Mini Mental Status Exam. Physicians use the mini mental status exam (MMSE to test a patient's cognitive function. The test is made up of a set of questions, testing the patient’s memory, orientation and arithmetic calculation skills. There is a...
Psychiatry code update
May 1st, 2013 - Codapedia Editor
I have attached a word document that you can print that explains the use of the new codes.
EMRs - Coding and Compliance Concerns
April 24th, 2013 - Allison Singer, CPC
Introduction The past year has been an exciting time for healthcare professionals, bringing more changes, opportunities and challenges than ever before. The Health Information Technology for Economic and Clinical Health (HITECH) Act, which is a portion of the American Recovery and Reinvestment Act...
Medicare as a Secondary Payer and Consults
January 10th, 2011 - Codapedia Editor
Now that Medicare doesn't recognize consults (effective 1-1-10), how will we bill for patients who have a commercial insurance as primary, and Medicare as a secondary payer? There are no great options. Options for office “consults” Bill primary with consult codes. Will cross...
Subsequent nursing facility visits
March 17th, 2010 - Codapedia Editor
Subsequent nursing facility visits (99307--99310) are services billed for either mandated or medically necessary visits in a skilled nursing facility or nursing facility. (Place of service 31 for a skilled nursing facility or 32 for a nursing facility). These codes may also be used in place of...
Can a physician practice open an office in a nursing home?
March 17th, 2010 - Codapedia Editor
,Physician visits in a nursing home are billed with nursing facility codes and place of service. But, what if a physician opens an office there? Are those services billed as office visits? A physician practice may established an office in a nursing home, if it pays rent at market value, and is...
Nursing home discharge services
March 17th, 2010 - Codapedia Editor
Either a physician or an NPP may bill for discharge services from a skilled nursing facility or a nursing facility. There are two discharge day management codes from a nursing facility. 99315 is for discharge day management 30 minutes or less, and 99316 is for discharge day management over 30...
Annual Nursing Facility Assessment
March 17th, 2010 - Codapedia Editor
CPT® code 99318 is used to bill an annual nursing facility assessment. It requires three of three of these components: a detailed interval history, a comprehensive exam, and low or moderate medical decision making. This visit is payable once per year for a resident in a nursing facility. ...
Can we bill a nurse visit to Medicare in an RHC?
January 30th, 2010 - Codapedia Editor
No, a practice may not bill a nurse visit to Medicare in a Rural Health Clinic (RHC.) Rural Health Clinics are designated by Medicare. In some states, the RHC will also be designated as a RHC by Medicaid. When so designated, the clinic is paid an all-inclusive rate for services performed on that...
January 30th, 2010 - Codapedia Editor
Updated: Dec 16, 2009 By now, we have all heard that CMS will not pay for consuts starting Jan 1, 2010, but we had lingering questions about how to submit claims. Dec 15, CMS released a transmittal, dated Dec 14, 2009, which answers these questions. The transmittal is attached. For services that...
Who can document the HPI?
January 30th, 2010 - Todd Thomas
A common question amongst coders that routinely deal with E&M services. The E&M Guidelines specify which elements can be recorded by someone other than the physician. "The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the...
An Eye on Coding
January 30th, 2010 - Nancy Maguire
An "Eye" on Coding Ophthalmology coding is an interesting specialty, especially when it comes to assigning a level of evaluation and management code. Coders outside this specialty may not realize that there are two sets of codes available to the eye specialist. The first set is one...
Pre-operative medical exams
January 28th, 2010 - Codapedia Editor
Medically necessary pre-operative evaluations are covered services by Medicare and other third party payers. Typically, the surgeon who will perform the surgery asks the patient's primary care physician or sub-specialist to clear the patient prior to a major surgery. This service must be medically...
UPDATE Post op care and hospitalists after the consult changes
December 17th, 2009 - Codapedia Editor
Change: December 15, 2009--Good news! The consult change would seem to allow hospitalists to bill for post op care using the initial hospital care codes. Here is a post by Seth Canterbury, published with his kind permission, about the topic. I read it to allow everyone's initial inpatient visit...
CPT® Consult Rule Changes for 2010
November 2nd, 2009 - Codapedia Editor
By now you've heard the news that starting January 1, 2010, Medicare will no longer reimburse consultation services billed with codes 99241--99245, 99251--99255. But, the consult codes remain in the CPT® book for 2010. However, there is quite a bit of new editorial material related to...
Primary Care Billing Profiles
October 14th, 2009 - Codapedia Editor
For most primary care physicians, Evaluation and Management services comprise the highest percentage of services performed, and account for most of the revenue. Primary care physicians should regularly compare their profile with the norm for their specialty. These specialty norms are included as a...
Observation initial services
September 8th, 2009 - Codapedia Editor
Observation services are a status of admission to the hospital. Patients who are admitted to the hospital are admitted either to inpatient status or observation status. The status is determined by the physician, although often the case manager at the hospital will have significant input into the...
Prolonged services for office and outpatient visits
July 31st, 2009 - Codapedia Editor
This is an article describing using prolonged services codes in an office setting. There is a separate article in Codapedia about using prolonged services codes in an inpatient setting. There is an article describing using non-face-to-face codes, as well. Prolonged services codes are add-on...
G0101 Pelvic and breast exam
July 6th, 2009 - Codapedia Editor
Medicare does not pay for routine physical exams annually for patients--a sore spot for Primary Care Providers and Medicare beneficiaries alike. They do pay for an initial Welcome to Medicare visit. (See the Codapedia article about that topic.) Medicare does pay for a screening pelvic and breast...
Chemotherapy Infusion and E/M on the same day
July 3rd, 2009 - Codapedia Editor
Is it appropriate to bill an E/M service with a chemotherapy infusion? Here is how Nancy Maguire answered that question: If a significant separately identifiable evaluation and management service is performed, the appropriate E & M code should be reported utilizing modifier 25 in addition to...
Nurse visits in provider based clinics
May 27th, 2009 - Codapedia Editor
Question: Can you bill a nurse visit, 99211, to Medicare in a Provider Based Entity? Answer: You may not bill a nurse visit to Part B, for a physician service, but may bill a facility fee for a nurse visit in a PBE. Discussion: Discussion: The payment rules for a free-standing,...
ROS Checklist
April 22nd, 2009 - Rikki Runyon
Review of Systems CHECKLIST: -General- ? Weight loss or gain ? Fatigue ? Fever or chills ? Weakness ? Trouble sleeping ----------------------------------------------------------------------------------- -Skin- ? Rashes ...
Services in an assisted living facility
April 22nd, 2009 - Codapedia Editor
According to the CPT® book, assisted living services are reported with codes 99324--99337. Look at that series of codes for new or established patients. It is not correct to bill at an assisted living facility with office visit codes. These codes are used for services provided in: domiciliary,...
E/M service with no exam
April 13th, 2009 - Codapedia Editor
Does an E/M service require an exam? It depends on the category of service. Established patients and subsequent hospital visits require two out of three of the key components, history, exam and medical decision making. Any two components at the level of documentation required determines the level...
Incident to Billing or Incident to Service
April 10th, 2009 - Jeannie Cagle, BSN RN CPC
By Jeannie Cagle, BSN, RN, CPC This question appeared in a recent list serve. My two responses are based upon two different assumptions: (1) both providers are physicians, and (2) one of the providers is not a physician. The principal points are that each physician has a unique National Provider...
Category of outpatient services
April 10th, 2009 - Codapedia Editor
New patient codes 99201–99205 may be billed in an office, outpatient department or Emergency Department. What is a new patient? The CPT® and Medicare (CMS) definition are the same. From the CPT® book: A new patient is one who has not received any professional services from the...
Department of Transportation DOT exams
March 31st, 2009 - Codapedia Editor
How does a physician report performing a Department of Transportation physical? With CPT® code 99455 and ICD-9 code V70.5, 99455 is for a work related or medical disability examination by the treating physician. (9945 is for this examination by other than the treating physician.) See the...
Suture removal
March 30th, 2009 - Codapedia Editor
If a physician removes sutures that he/she placed, and the service has a ten day global period, there is no separate payment for the suture removal. It is part of the global service and payment for the minor procedure. However, insurance companies will pay for suture removal performed by a...
Do headings matter in an E/M note
March 30th, 2009 - Codapedia Editor
When documenting the history components in an Evaluation and Management service, the clinician is not required to use the headings that the Documentation Guidelines define. That is, the history section does not need to be labeled: History of the Present Illness, Review of Systems, and past medical,...
Is time the trump card in selecting an E/M service?
March 29th, 2009 - Codapedia Editor
Is time a trump card in selecting an Evaluation and Management service? Sometimes. Isn't that too frequently the answer in coding? If the visit meets the criteria for using time ot select the code, and if time is a descriptor in the CPT® definition, then yes. The criteria are: ...
Is medical decision making a trump card in E/M services?
March 29th, 2009 - Codapedia Editor
Physicians who treat patients with very serious illnesses sometimes think that they can select the highest level of service in any category based on the high acuity of the patient. After all, isn't a patient with a brain cancer really sick? Shouldn't that patient always be charged a high level...
Second opinions: are they consults?
March 27th, 2009 - Codapedia Editor
There are no longer any CPT® codes for confirmatory consults. If a patient presents to the office with a request for a second opinion, how is that billed? If the patient is requesting a second opinion, bill that service as a new or established patient, whichever category is correct for that...
Ventilator management
March 18th, 2009 - Codapedia Editor
There are two codes for ventilator management for inpatient services: 94002 and 94003. One is for the day when the physician initiates vent management and the second is for a subsequent day. They are mutually exclusive codes in the CCI edits and may not be billed together on the same day. See the...
Can a physician be paid for reviewing old records and x-rays
March 13th, 2009 - Codapedia Editor
A patient presents to the office with 100 pages of old records and a dozen x-ray copies to review prior to consultation. How can a physician be paid for that? There is no separate reimbursement for record review. With the development of RBRVS, the pre and post work of services is included in the...
Can consults be billed based on time?
March 12th, 2009 - Codapedia Editor
Yes, both inpatient and outpatient consults may be coded based on time, when the conditions for using time are met. CPT® tells us that a physician or NPP may use time to select a code when counseing "dominates" the visit. CMS confirms these rules in their Documentation Guidelines....
Coding for visits to patients in Swing Beds
March 12th, 2009 - Codapedia Editor
Physicians should bill for patients in facilities based on the status of the patient in the facility. This is true for Observation, Inpatient and nursing facility status. The status billed by the facility and the E/M codes selected and reported by the physician should match. Some hospitals have...
Initial hospital services that dont meet 99221
March 10th, 2009 - Codapedia Editor
Sometimes, when auditing an initial hospital service, either the history or the exam does not meet the level required for the lowest level of initial hospital service. 99221 requires all three of: a detailed history, a detailed exam and straightforward or low medical decision making. The MDM is...
Can prolonged services be added to preventive medicine codes?
March 9th, 2009 - Codapedia Editor
There are two sets of prolonged services codes, one set for face-to-face additional time spent with the patient in the office or hospital, and one set for non-face-to-face time. Non-face-to-face time is typically not paid by most insurers. In 2009, CPT® changes its description of these...
Can a Physicians Assistant do a consult?
March 9th, 2009 - Codapedia Editor
This question comes up at seminar after seminar. Someone says, "My billing manager told me that PAs (or NPs) can't do consults. Is that true?" It is a half truth. PAs and NPs may perform consults, as long as consults are in their state scope of practice. They may perform consults on...
Do you need three vital signs for it to count?
March 4th, 2009 - Codapedia Editor
This is one of the most common questions physicians and NPPs ask at coding conferences. Do I need to document three vital signs for it to count. It depends on which set of guidelines the clinician is using. For 1995, no. Any one vital sign or general appearance counts for constitutional. For...
Comprehensive exam, 1995 Giudelines
March 4th, 2009 - Codapedia Editor
A comprehensive exam using the 1995 Guidelines requires eight organ systems. You may not count body areas. The Guidelines do not give any definition about how much must be examined in each system, and auditors typically count anything within that system. The Guidelines say, Comprehensive -- a...
Anticoagulant management
March 3rd, 2009 - Codapedia Editor
In 2007, CPT® added two codes for anticoagulant management, 99363 and 99364. The codes are meant to be used by physicians and Non-Physician Practitioners (NPPs) who manage a patient's warfarin therapy on an outpatient basis, reviewing the PTINR, adjusting the patient's dosage as appropriate,...
Consults in a group
February 23rd, 2009 - Codapedia Editor
Can one physician request a consult from another physician in the same group? Sometimes. (Don't we long for yes or no answers?) One physician can request a consult from another physician in the same group, of the same or different specialty, when the conditions of a consult are met, and the...
Hospitalist Services
February 12th, 2009 - Codapedia Editor
Hospitals are adding hospitalist services at a fast pace. Everyone is recruiting for hospitalists. It's changed the face of primary care. Primary care physicians are now in their offices more hours of the day. Their hospitalized patients are cared for by a group of physicians without office...
Observation discharge
February 12th, 2009 - Codapedia Editor
There is only one code for observation day discharge management, 99217. Unlike discharge day management from inpatient status or nursing homes, there are not two levels based on time. Use 99217 no matter how long the discharge takes. The patient status must be Observation status to use this...
Hospital Discharge Day Services
February 12th, 2009 - Codapedia Editor
Use codes 99238 or 99239 for services provided to a patient being discharged from inpatient status in the hospital. These codes include all of the work performed on the calendar day to discharge a patient, including the exam, discussion with the patient and caregivers, and discharge paperwork. ...
Auditing the exam 1995 Guidelines
February 11th, 2009 - Codapedia Editor
Auditors breathed a huge sigh of relief when the 1997 Guidelines were released. The exam component was specific, clear and defensible in all four areas: problem focused, expanded problem focused, detailed and comprehensive. There were even specific instructions for single specialy exam elements. ...
Mandated visits in a nursing facility
February 11th, 2009 - Codapedia Editor
What are mandated nursing home visits and who mandates them? May either a physician or qualified Non-Physician Practitioner (NPP) perform these? CMS mandates that residents in nursing homes be assessed by a physician or NPP at periodic intervals. This is a requirement for the nursing home's...
Physicians in a Group
February 9th, 2009 - Codapedia Editor
Medicare and other third party payers pay have specific rules for paying physicians of the same specialty in a group. Here is what the Medicare Claims Processing Manual says: 30.6.5 - Physicians in Group Practice (Rev. 1, 10-01-03) Physicians in the same group practice who are in the same...
Interval History
February 9th, 2009 - Codapedia Editor
Some CPT® codes require an interval history. This article defines an interval history.
Are two E/M services payable on the same day?
February 9th, 2009 - Codapedia Editor
There are times when physicians or NPPs see a patient twice in a single day, and want to know if both are reportable, and if both are paid by insurances or Medicare. In general, only one service is paid, but there are some instances in which both can be paid.
E/M Profiles
January 29th, 2009 - Codapedia Editor
CMS and other payers collect data on the utilization of E/M services within each category of service. For example, for all of the established patient visits billed using codes 99211 to 99215 by Rheumatologists, CMS keeps track of what percentage are level one’s, level two’s, level...
Consultation services
January 29th, 2009 - Codapedia Editor
Let’s start with Medicare’s definition of a consultation Medicare Claims Processing Manual, Publication 100-04, Chapter 12, Section 30.6.10A Carriers pay for a reasonable and medically necessary consultation service when all of the following criteria for the use of a consultation code...
Critical Care and the Teaching Physician Rules
January 29th, 2009 - Codapedia Editor
Only the time of the teaching physician--not the resident--may be reported as critical care time. That's the short answer. Review the articles in Codapedia related to the requirements for critical care billing and critical care to neonates and pediatric patients. Only the attending physician...
Critical care
January 29th, 2009 - Codapedia Editor
Critical care services are services provided to a critically ill patient. It sounds like a circular definition.doesn't it? The first requirement for billing critical care is the status or condition of the patient. Although critical care services are often provided in a criticla care unit,...
Welcome to Medicare Visit
January 29th, 2009 - Codapedia Editor
Welcome to Medicare Initial Preventive Physical Examination (IPPE) A new benefit under the Medicare Modernization Act Effective date 1-1-05, changes for 2009 Eligibility: Any Medicare beneficiary who enrolls in Medicare on or after January 1, 2005 Time limits: Eligible for benefit in the...
January 28th, 2009 - Codapedia Editor
CPT® defines two sets of consultation codes: outpatient/office consults using 99241 through 99245 and inpatient/nursing facility consults using codes 99251 through 99255. The Center for Medicaid and Medicare Services (CMS) defines a consult in this way Specifically, a consultation service is...

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