How are E&M codes determined?
Evaluation and Management (E/M) codes are determined primarily by Medical Decision-Making (MDM) or Total Time spent on the date of the encounter.
1. Key Factors for Code Selection
- Place of Service: The setting of the care (such as an office, emergency department, inpatient hospital, or nursing facility).
- Patient Status: Whether the patient is new (has not received professional services from the provider or the same specialty/subspecialty in the practice within the past 3 years) or established.
- Method of Selection: Choosing either MDM or Total Time (whichever the provider prefers or the guidelines specify for that category).
2. Medical Decision-Making (MDM)
To determine an E/M level using MDM, you must meet or exceed two out of the three following elements:
- Number and complexity of problems addressed: Ranging from minimal/straightforward issues to multiple chronic or severe acute illnesses.
- Amount and/or complexity of data reviewed and analyzed: Reviewing external notes, ordering/reviewing tests, or talking with an independent historian.
- Risk of complications and/or morbidity/mortality: The potential risk to the patient from the condition, diagnostic testing, or treatment management choices.
MDM is categorized into four distinct levels: Straightforward, Low, Moderate, and High.
3. Total Time
For many E/M categories, you can select the code based on the total time personally spent by the physician or qualified healthcare professional on the date of the encounter.
- What counts: Face-to-face time with the patient, plus non-face-to-face tasks like reviewing test results, writing medical records, and coordinating care.
- What does not count: Time spent by clinical or ancillary staff (like nurses or medical assistants).
4. Medical Necessity
- Overarching Rule: The level of service billed must be justified by the patient's symptoms and the actual care required, not just the volume of documentation or the time spent.