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Evaluation and management coding is a type of medical coding used by physicians and certain other healthcare providers to report their services as part of medical billing. Evaluation and management (E/M) codes are found in the CPT® code set in the range 99202-99499 and cover a variety of services. Many E/M codes, such as those for inpatient care and home visits, include a combination of patient history, examination, and medical decision making (MDM).
These factors — history, exam, and MDM (HEM) — are known as the three key components of E/M level selection. Determining the correct type of history, exam, and MDM can feel intimidating even for seasoned coders because of the many requirements involved. A solid understanding of these three key components will help ensure more accurate coding and reimbursement for E/M codes.
1. determine the type of history . A patient history includes getting the chief complaint and the history of the present illness. The history also may include a review of body systems using questions to identify signs and symptoms, and a review of the patient’s past, family, and social history, depending on what is medically appropriate for the visit. The amount of history taken will determine the type: problem focused, expanded problem focused, detailed, or comprehensive.
2. determine the type of the physical exam. The provider uses clinical judgment to determine the extent of physical examination needed for each of the patient’s body areas and organ systems. The provider will document one of these four types of exam: problem focused, expanded problem focused, detailed, or comprehensive.
3. determine the type of medical decision making (MDM). MDM is how the provider rates the degree of difficulty in establishing a patient’s diagnosis and treatment plan. E/M codes include four types of MDM: straightforward, low complexity, moderate complexity, and high complexity.
4.determine the final code. Once the provider has determined the types of history, exam, and MDM, final E/M code selection can occur based on those three key components. For this example, assume the physician performed a comprehensive history, a comprehensive exam, and medical decision making of high complexity for this new patient. The appropriate code in this case is 99328 Domiciliary or rest home visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity.
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