E/M Coding: What Your Medical Practice Should Know

March 23, 2022 by Antonio Arias, MBA, CHBME

Topics: Medical Billing, Practice Management

Evaluation and management coding, known as E/M coding, is a critical component of your medical practice since evaluation and management are likely part of any interaction you have with patients. As such, coding practices for E/M services need to be specific and can lead to suspicion or audits if your medical practice has a history of inaccurate E/M coding on claim submissions.

With the level of importance attached to E/M codes, it’s helpful to know that CMS regulations regarding E/M coding recently changed, too. Keep reading to learn what E/M codes are, and get some billing tips for your medical practice to follow.

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What Are E/M Codes?

Evaluation and management coding involves CPT codes that specifically represent services provided by a physician or other qualified healthcare professional; these codes range from 99209 to 99499. E/M services might include office visits, home services, and preventative visits; other types of healthcare services, like surgeries, are not included in this range of CPT codes for E/M services.

When billing Medicare for E/M services, you must select the CPT code that best represents the following:

  • Patient type, whether new or established
  • Setting of service, whether office or outpatient setting, hospital, emergency department, or nursing facility
  • Level of E/M service provided, typically the more complex visit correlates with a higher level code

When determining what level of service was provided, consider the level of history, examination, and medical decision-making that was involved. An important exception to this guidance is if the visit was primarily counseling or coordination of care—in this case, select the code that correlates to the length of time spent with the patient.

evaluation and management is important for your medical practice

Why Is Accurate E/M Coding Important?

Since evaluation and management services are so frequent for your medical practice, small mistakes in the coding of these services can lead to compliance or payment issues if there’s a pattern of inaccuracies. For example, if you overestimate or over-report the amount of time spent with patients that exceeds what a reasonable day would be—say, spending 1 hour with 20 different patients in one day—that could raise a red flag and lead to audits or further questioning by your payers.

Accurate E/M coding is important too for the sake of maintaining accurate and comprehensive medical record documents; E/M services are vital to the patient-provider interaction and for establishing a patient’s healthcare journey, so accurate coding and reporting on these measures help you and your patient.

Medical Coding Tips: 3 Things to Know About E/M Coding

Since evaluation and management coding is so crucial to your medical practice and the patients you care for, it’s helpful to know a few essentials:

1. The Latest Medicare Final Rule Impacting E/M Coding

In November of 2018, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that included updates to a variety of regulations taking effect on or after January 1, 2019. The purpose of this ruling was to streamline administrative workflows and reduce unnecessary burdens. 

You can read more about the specifics listed in Medicare’s press release regarding the final rule here, but here are a few key highlights—some of which took effect as recently as last year in 2021:

  • Payment for E/M office/outpatient visits will be simplified and payment would vary primarily based on attributes that do not require separate, complex documentation
  • Reduction in the payment variation for E/M office/outpatient visit levels by paying a single rate for E/M office/outpatient visit levels 2 through 4 for established and new patients while maintaining the payment rate for E/M office/outpatient visit level 5 in order to better account for the care and needs of complex patients
  • Adoption of a new “extended visit” add-on code for use only with E/M office/outpatient level 2 through 4 visits to account for the additional resources required when practitioners need to spend extended time with the patient

Essentially, these new regulations allow for more flexibility in terms of medical documentation and optimizing workflows to not have unnecessary repetitiveness. Be sure to review your medical practice’s operations to confirm that you’ve implemented these requirements and that you’re staying compliant.

2. New Patient vs. Established Patient

Clarifying if the patient you provided E/M services to is a new or established patient is an important part of accurate E/M coding! Let’s briefly break down what each one means to your practice:

  • New patient: An individual who hasn’t received any services from a physician/non-physician practitioner (NPP) or any other physician of the same specialty who belongs to the same practice within the last 3 years
  • Established patient: An individual who has received services from a physician/NPP or anyone else of the same specialty and who belongs to your practice within the last 3 years

For example, if a patient returns to see a cardiologist within a major medical group and happens to get recommended to see a dermatologist regarding a lesion on their skin, the patient is a new patient for the dermatologist because it’s a different specialty than the original established purpose of cardiology.

accurate e/m coding helps your medical revenue cycle

3. Common E/M CPT Codes

What are the most common E/M codes you'll see? If you’re billing for time-based E/M services, keep these codes handy:

  • 99202: 15-29 minutes
  • 99203: 30-44 minutes
  • 99204: 45-59 minutes
  • 99205: 60-74 minutes
  • 99212: 10-19 minutes
  • 99213: 20-29 minutes
  • 99214: 30-39 minutes
  • 99215: 40-54 minutes

When billing based on the complexity of the evaluation and management services provided, consider these codes:

  • 99212: straightforward level of complexity, minimal risk or chance of complications
  • 99213: low level of complexity, low risk or chance of complications
  • 99214: moderate complexity, moderate risk, or chance of complications
  • 99215: high complexity, high risk, or chance of complications

Partner with NCG Medical Services to Handle Your Medical Billing!

As you well know, there are dozens of codes in addition to E/M codes and numerous factors to consider when handling your medical and billing processes. It can feel overwhelming to keep track of all of them—plus stay on top of updated regulations and guidelines for accurate coding. Since the success of your practice predicates upon efficient and effective coding, you can’t just put off doing this cornerstone component of your operations!

Partner with NCG Medical Services to handle your medical billing and coding from start to finish. Our team of experts has experience in your specialty and we’re eager to take this huge responsibility off your shoulders so you can focus on what matters most: your patients.

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