MEDESUN® MEDICAL CODING ACADEMY

Evaluation and
Management Coding
-2024-
CPT®

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EVALUATION AND MANAGEMENT

Evaluation and management codes, often referred to as E&M codes or E and

M codes are a coding system that involve the use of CPT codes from the range
99202 to 99499 which represent services provided by a physician or other
qualified healthcare professional

Assign EM Code when the provider is involved in evaluation and management

of patient health – Mostly Office Visits, ED, Home, Consultations etc.

The provider evaluates signs, symptoms, or overall health of a patient and

manages any diseases or illness the patient has.
EVALUATION AND MANAGEMENT

Office visits, hospital visits, home services and preventive medicine services
are considered E&M codes.

Codes for procedures like surgeries, radiology and diagnostic tests, and
certain treatment therapies are not considered evaluation and management
services.

E&M coding is not about procedures or tests but rather focuses on the cognitive
services provided by healthcare professionals, such as patient consultations,
physical examinations, and medical decision-making processes.
EVALUATION AND MANAGEMENT

The Physician may perform following

 Inspection and observation

 Palpation- examination by touch

 Auscultation-listening to body sounds

 Percussion-Creating sounds from tapping on body areas

Physician/Qualified Healthcare Professional documents Chief complaint, History of

present illness, past medical, social history etc.
ICD-10-CM CODING

Primary diagnosis
 reason for the visit

Signs and Symptoms

 Report all if no definitive diagnosis is stated
 Report any symptom not routinely associated with the definitive diagnosis
 Not reported if symptom is associated with definitive diagnosis
ICD-10-CM CODING EXAMPLE

When a patient visits a provider with symptoms such as a cough or chest pain and the
provider documents a definitive diagnosis, only the definitive diagnosis should be
coded.

If a symptom is unrelated to the normal process of the disease, it can be coded in

addition to the disease.

For example, if a patient visits the doctor for hypertension follow-up but also reports
knee pain, and both are evaluated, both should be coded.

However, if the patient complains of headaches and the provider determines they are
due to high blood pressure, only the hypertension should be coded.
OFFICE VISITS
NEW VS. ESTABLISHED PATIENTS

New – has not received any face-to-face professional services from the
physician/qualified health care professional, or a physician/qualified health
care professional of the exact same specialty/subspecialty within the group
practice, within the last three years

Established – has received face-to-face services in the last three years

One of the key areas in the definition of a new patient is where it states the
physician of the same specialty or subspecialty. For example, if a patient
sees an internist on a regular basis, but then breaks his leg and sees an
orthopedist in the same practice. This patient would be considered new to
the orthopedist because the physicians are of different specialties.
INITIAL AND SUBSEQUENT VISITS

• An initial service is the first face-to-face visit by a provider.

• If seen by another provider in the same group that is of the same specialty
and subspecialty, during the same stay, the second provider reports a
subsequent service.
OFFICE OR OTHER OUTPATIENT SERVICES

Provided in an office or other outpatient clinic or ambulatory facility

• New patient

• Established patient
MDM

Medical Decision Making

• Assign the EM code based on the location ( Office, home, ED etc)

• Analyze the MDM Level

MDM depends on
• Complexity of problems addressed
• Data – amount and complexity of data reviewed/analysed
• Risk – of complications mortality/morbidity
MDM
EM CODE – MD LEVEL
REFER PAGE # 9/10/11- CPT MANUAL
EM CODING BASED ON TIME
TIME

The amount of time or the total time of the encounter on the date of the
encounter determines the appropriate evaluation and management CPT codes.
This can include face-to-face and non-face-to-face time personally spent by the
physician
EXAMPLE-1
75-Year-Old Male with Parkinson's Disease
Six month follow-up visit, in the last few months, he has been stable, tremor unchanged,
no postural instability, sleep is good, and no falls: pt is Spanish speaking, primary
caretaker recently diagnosed with cancer.
• Pre-Visit: Reviewed his last f/u note with you, PCP notes, physical therapy notes
for gait training exercises [3 MINS]
• Visit: You obtain a history from the patient, asking about sleep, ambulation,
overall function, doing a focused exam [20 MINS]
• Post-Visit: Document his visit [2 MINS]

Answer- Follow-up – Established Patient

Total time of visit (includes pre-visit and post-visit time on calendar day): 25 minutes
Established patient, level 3 = 20-29 minutes
CPT 99213
EXAMPLE-2

62 year old female here for follow up of Left Breast lump

HPI Patient X reports feeling anxious today. She is here to discuss the
results of her most recent mammogram and ultrasound
Exam
Deferred
Total Time of the visit: 30 minutes

EM Code - 99214
EXAMPLE-3

Patient presents with an acute fever, abdominal pain, and painful urination for
two days. The provider documents the medical history and exam. The provider
orders a urine analysis, which comes back positive and prescribes an
antibiotic.

Refer Page # 10 MDM Table in CPT Manual

Complexity – LOW – one acute uncomplicated
Data ( New test ordered)- Low
Risk – Prescription Drug Management
Hence the EM Code is 99213 – Low MDM
EXAMPLE-4

An established patient who has a follow up office visit for asthma

management. The provider documents a medically appropriate history
and exam and reviews an independent interpretation of a pulmonary
function test. The provider makes a change to current medication and
sends to the pharmacy.

Answer-
Complexity of Problems – One stable chronic illness- LOW
Data- Reveiwed OLD data and ordered new – Moderate
Risk- Prescribed Drug- Moderate

EM Code is 99214
EXAMPLE-5
CC- Patient complains of fever, sore throat and facial pain
Physician documented HPI, ROS and PE
Ordered Rapid throat culture- Positive
Diagnosis: Strep Pharyngitis
Medication- Penicillin Injection

Answer
Complexity – One acute , uncomplicated illness - LOW
Data – Ordered New test - LOW
Risk- Prescription Drug Management – Moderate

EM code - 99213
 EXAMPLE-6
Chief Complaint: Patient returns today for a note to return to work after testing
positive for Covid.
HPI: Patient was seen two weeks ago for Covid. Asymptomatic today and
negative test from Quest. (Total time in review 2 minutes)
Exam: Patient is in no acute distress Afebrile. Lungs clear to auscultation, denies
malaise. (Total time 5 minutes)
Assessment: Viral illness resolved. A note was given to return to work. Return to
clinic as needed. (Total time 3 minutes)
Documentation in Medical Record total time 2 minutes.
Code Selected 99212 or 99211
Rationale 99212-time range is 10-19 minutes
or by MDM comparison code is 99211
NOTE: You can assign code based on time or MDM- Depends on question/payer
guidleines
EXAMPLE-7

Office visit for a 17-year-old male, established patient, with stable

schizophrenia on clozapine who was scheduled for an urgent visit after he
was noted to have new-onset neutropenia on clozapine-monitoring blood
work.

Complexity – High ( One illness-severe exacerbation)

Risk- High – (Drug therapy requiring monitoring)
Refer MDM table in CPT Manual-Page 10
CPT Code - 99215
EXAMPLE-8

Office visit for a 16-year-old female, established patient, with long-

standing depression and recent intermittent moderate sadness.
Prescribed medications

Complexity- One chronic illness with exacerbation - Moderate

Prescription drug management – Moderate

Code – 99214
EXAMPLE-9

Initial office visit for an adolescent urgently referred after cutting wrists
superficially with suicidal intent. The adolescent reports a relapse of
chronic depression and hospitalization is considered.
Code- 99215- High MDM