Evaluation and Management (E/M) are a very important part of what surgeons do. They comprise consultations, office follow-up visits, hospital admissions, emergency department consultations, hospital follow-ups, critical care services, and on and on. E/M services also include the follow-up visits for surgical procedures with “global ” payment, wherein we do not charge separately (but are paid nonetheless) for postoperative visits.
E/M services represent a large amount of money to the government and to insurance payors. Hence, the rules for paying for E/M services and the documentation requirements have become very important issues.
Documentation Guidelines
In 1994, the AMA and CMS collaborated to develop documentation guidelines (DGs) for E/M reporting. Those guidelines were implemented in 1995 and have become known as the 1995 Documentation Guidelines . In 1997, CMS wrote a revised version, adding specific elements that should be performed and documented for examinations focusing on specific organ systems. This revision resulted in the 1997 Documentation Guidelines . CMS allows providers to use either set of DGs.
Prior to these publications, CMS and others defined general principles of medical record documentation that are applicableto either set of DGs. These principles should be remembered in all documentation, and they can be modified to fit most any circumstance in E/M coding.
STEPS TO FOLLOW FOR E/M CODE SELECTION
1.Identify the category and subcategory of service. Is this an office visit with an established patient? Initial inpatient consultation? Comprehensive nursing facility assessment? New patient home services? Individual counseling for preventive medicine services? Visit to the emergency department? Hospital outpatient service?
2.Review specific notes and instructions for the selected category and subcategory.
3.Review the narrative descriptors within the category and subcategory of the E/M services.
4.Using the definitions provided under each level of service, determine the extent of history obtained.
5.Determine the extent of examination performed using the definitions provided under each level of service.
6.Determine the complexity of medical decision making.
7.Select or verify the appropriate level of E/M service.
Categories of E/M Services
Below list shows the current categories of E/M services. All E/M services consist of the following five elements:
1.A unique CPT code number beginning with 99
2.Identification of the place or type of service (for example, office or other outpatient service; initial or subsequent hospital care)
3.Definition of the extent or level of service (for example, detailed history and detailed examination)
4.Description of the nature of the presenting problem (for example, moderate severity)
5.Identification of the time typically required to provide a service
