Here’s a nuts-and-bolts guide to the E/M section in your CPT maual.

If you’re a lab, pathology, or radiology coder, the evaluation and management questions may have you re-evaluating whether you want to take the test in the first place. Relax. My Coding Career is here to help, and this post is designed to school you in the basics.

Tip: For more CPC exam prep help with E/M coding, check out this E/M coding lingo page, as well as posts about particular E/M issues like ‘time.’ Don’t see something you need to prepare for the CPC exam? Write us here at My Coding Career.

Open-Book Test Tip: As you study for the exam’s E/M questions, keep your CPT manual book open and mark important points. If you’re very familiar with what’s in your CPT manual, your odds of discovering the correct answer in your book are higher.

How Your CPT Manual Organizes E/M Codes

CPT divides E/M services into visits and consultations. These categories are further divided — office visits into new or established patients; hospital visits into initial and subsequent; and consultations into outpatient and inpatient. CPT further divides such categories and subcategories based on the type and place of service and the patient’s status.

Note: Even though Medicare no longer accepts consultation codes in 2010, some private payers do accept them and they are still in your CPT manual. So, focus on the E/M guidelines in your CPT manual to answer test questions.

CPT uses the same basic format to describe the E/M service levels for most categories:

1. listing a unique code;
2. specifying the place and/or type of service; for example, an outpatient consultation;
3. defining the services content; for example, a comprehensive history, comprehensive examination and moderate medical decision-making;
4. describing the nature of the presenting problem(s) usually associated with a given level; and
5. specifying the time typically associated with the service.

Levels of E/M Service

There are three to five E/M service levels available for reporting purposes within each E/M code category or subcategory. Levels of E/M services are not interchangeable among the different categories or subcategories. For example, the first level of E/M services for a new patient office visit does not have the same definition as the first level of E/M services for an established patient office visit.

The descriptors for the E/M service levels recognize seven components, six of which CPT uses in defining the E/M levels. These components are:

1. history
2. examination
3. medical decision-making
4. counseling
5. coordination of care
6. nature of presenting problem
7. time.

The first three of these components (history, examination and medical decision-making) are considered the key components when selecting an E/M service level.

The next three components (counseling, coordination of care and the nature of the presenting problem) are considered contributory factors in most encounters. Although the first two of these contributory factors are important E/M services, the healthcare provider doesn’t need to provide them at every patient encounter.

The actual performance and/or interpretation of diagnostic tests/studies ordered during a patient encounter are not included in the E/M service levels. You may separately report your physician’s performance of diagnostic tests/studies for which specific CPT codes are available, in addition to the appropriate E/M code. In addition, you may separately report the physicians interpretation of diagnostic tests/studies results with preparation of a separate distinctly identifiable signed written report using the appropriate CPT code with modifier 26 (Professional component).

Commonly Used E/M Terms

When you’re reviewing E/M rules and regulations, there are certain terms that you’ll see frequently, including the following:

Adapted from the E/M Coding Survival Guide. Use the complete guide to study for the exam when you sign up for Supercoder.

Already an E/M whiz? Get your CEMC.

Watch out. Modifier 57 or 24 may actually be the code you should use.

Checklists can help you code correctly and avoid audits, so here’s a checklist to help you with one of coding’s most problem-plagued topics: modifier 25.

To ease payment for your modifier 25 claims, check your claim against the following:

√ Append modifier 25 to the E/M service only if the same-day procedure is a minor procedure (that is, the procedure does not have a 90-day global period). For E/M services on the same day as a major procedure (a procedure with a 90-day global period), modifier 57 is appropriate.

√ Have complete and separate documentation for the E/M service, apart from documentation for any other services/procedures the physician provides that day. Treat E/M codes as part of a different encounter. Documentation should independently support every code you claim.

√ Be sure that the E/M service you report is significant (in a best-case scenario, documentation should support at least a level-three patient encounter, such as 99203 or 99213).

√ Whenever possible, attach a different diagnosis to the E/M service. Although not required, a unique diagnosis helps establish the E/M services separately identifiable nature.

√ Use the appropriate narrative boxes on the CMS-1500/electronic form to explain the E/M services significant, separately identifiable nature.

√ Be certain that you are not billing for care included in a previous surgery’s global period. You may not separately report E/M services the surgeon provides during the global period of a related procedure.

Note: If the physician provides an E/M service during the global period of an unrelated procedure, however, you may report the appropriate E/M service code with modifier 24 (Unrelated evaluation and management service by the same physician during a postoperative period) attached.

This checklist comes from Supercoder.com. For more modifier checklists, check out the Modifier Survival Guide on Supercoder.com. A FREE, 30-day trial is open to all who visit the site.

Choice the wrong fork in the road & you wind up in Incorrect Code Land

When coding for evaluation & management services, it’s hard enough to verify place of service, discern components and select the correct level. But get the ‘new’ vs. ‘established’ distinction wrong, your coding’s lost its way.

Face-to-Face in 3 Years Makes an Established Patient

Generally, you should consider a patient to be established if any physician in your group practice (or more precisely, any physician of the same specialty billing under the same group number) has seen that patient for a face-to-face service within the past 36 months. CMS transmittal (R731CP, change request 4032, implemented Jan. 3, 2006) reinforces this policy on how to define new and established patients.

Location isn’t the issue: If your practice has multiple locations and a physician in location A sees the patient in January while a physician at location B sees the patient in December, the patient is still established. The need to create a new chart is inconsequential.

For instance: A primary-care physician recommends that a 65-year-old male see a cardiologist for a full workup. One of the physicians in the cardiologists practice provided an interpretation of an EKG for the same patient the previous year when he was in the emergency department, but provided no face-to-face service.

In this case, the cardiologist can still consider the patient to be new when selecting an initial E/M code because no physician within the practice provided the patient with a face-to-face service within the past three years.

Another example: A patient comes to your office complaining of low back and stomach pains. Although this is physician As first time meeting the patient, physician B, in the same group practice, saw the patient two years ago for a similar complaint.

In this case, you should consider the patient to be established.

Different Specialties Allow for Exceptions

The new patient rule applies only when physicians in the same practice are also of the same specialty.

Translation: If your practice is big enough and provides services for more than one specialty, two physicians may see a patient for completely different reasons. This could allow you to report a new patient visit even though two physicians in the same practice saw the same patient within a three-year period.

Example: A patient has been seeing an internist of a multispecialty group for the past three years for primary care, particularly, his hypertension. The internist identifies some suspicious lesions in January 2008.

The internist sends the patient to a general surgeon in the same practice to evaluate removing the lesions. Although the patient was a new patient to the internist in 2005, the patient is a new patient to the general surgeon in 2008 because he is a different specialty and the internist and the general surgeon are treating different problems.

Because the internist and general surgeon (who are obviously of different specialties) saw the patient for completely unrelated problems (this is key), you may report the general surgeons initial visit with the patient using the new patient codes.

Road Map: The E/M Services Guidelines chapter in your CPT book has a nifty decision tree to help you choose between ‘new & established.’ For example, it’s on page 2 of the AMA’s 2009 edition of CPT.

Reimbursement Road: Get the coding basics you need to arrive at the correct code. Coming soon to a city near you.