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American Association of Oral and Maxillofacial Surgeons

Practice Management & Allied Staff News & Materials

Evaluation and Management (E&M) Codes

February 15th, 2012

Evaluation and management (E&M) codes were designed to increase the level of accuracy for coders and include reporting levels for nonprocedural encounters. E&M codes were originally introduced in the 1992 Physicians CPT book and have been updated in every CPT book since.

There are different categories of E&M coding that define the wide variations in skill, effort and time. These are required for preventing, diagnosing and treating illness or injury, along with promoting optimal health. Along with the levels of E&M coding and the components, the physician will be able to determine the appropriate category of E&M coding. The different categories of E&M coding along with their subcategories are as follows:

  • Office or other outpatient services- new patient
  • Office or other outpatient services- established patient
  • Hospital observation services- initial care, subsequent, and discharge
  • Hospital inpatient services- initial care, subsequent, and discharge
  • Observation or inpatient care (including admission and discharge services)
  • Consultations- office or other outpatient
  • Consultations- inpatient

AAOMS recommends closely reading the Evaluation and Management Guidelines in the beginning of the CPT manual as well as the special instructions located under each E&M coding category included in the CPT book to gain a better understanding of how to code under each category.

There are seven components used to define the correct E&M code for every patient case. These seven include: History, Examination, Medical Decision Making, Counseling, Coordination of Care, Nature of Presenting Problem, and Time. The first three components (history, examination and medical decision making) are known as the key components in selecting the proper level of E&M code. For new patient exams, all three components must be met, but for established patient exams, at least two of the three key components must be met or exceed their stated requirements (intensities) to qualify for a level of E&M service. The following three components (counseling, coordination of care, and the nature of the presenting problem) are considered contributory factors. This means that although the first two of these factors are important E&M services, it is not required that these services are provided with every patient encounter. Once the components are recognized, the extent for the history obtained, extent of examination performed and the complexity of the medical decision making must be determined to properly choose the appropriate E&M code. Guidelines for determining the extents can be found in the Evaluation and Management section of the CPT book.

Time may be considered a key factor for qualifying for a specific level of evaluation and management services. Time with the patient should be noted along with the time spent with the patient's family/caregivers for counseling purposes (included within the E&M code). When the counseling takes up more than 50% of the face-to-face time with the patient/family, time may be the controlling factor of choosing an E&M code. If a patient is seen by the doctor more than once in 24 hours, only one E&M code may be billed, however, the complete time spent with the patient may be added to obtain a higher E&M level code.

To find more information on the Medicare documentation guidelines for selecting the proper E&M code visit the Centers for Medicare and Medicaid Services. The documentation guidelines can be downloaded at http://www.cms.gov/MLNEdWebGuide/25_EMDOC.asp.

Utilization and understanding of Evaluation and Management codes is essential to proper coding and reimbursement. Detailed instruction on Evaluation and Management Codes is provided in the AAOMS Coding Workshop series. Additional information on the AAOMS Coding Workshops may be found at http://www.aaoms.org.