The Insider’s Guide to Evaluation and Management

On this cool evening when I am chilling with my family I have got a mail from one my student, she said that she is getting lot of confusion while selecting the Evaluation and management coding over HCC Coding, she also mentioned that many of their colleagues also gave a suggestion like Evaluation and management is more difficult to process hence it is a great idea to enter into the HCC coding

If you are also thinking like this and you have got the suggestions exactly like this then this post is absolutely made for YOU only

In this article I wrote complete overview of E&M Coding and difference over HCC Coding, After this complete article you will get benefitted with good overview on Evaluation and management coding

What is Evaluation and management :

It is a process where patient comes with different complaints and gets evaluated by the Physician and Physician provides sufficient management (treatment) for that condition this is known as E&M. E&M Can be denoted with 5 digit CPT, Each E&M CPT denotes for specific RVU

RVU –> Relative value units

CF   –> Conversion factor

These factors will used for the payment purpose, We have lot of E&M CPT’S and each CPT has different money value, To learn E&M we must know the components of E&M

Evaluation and management coding guidelines :

There are 7 components in E&M and those are

History

Physical examination

Medical decision making (MDM)

Nature of presenting illness

Counselling

Time

Co-ordination of care

History, PE & MDM are known as “Key components” & the remaining are termed as “ Contributory factors”

Nature of presenting illness:

It is the main chief complaint of the patient or may be the sign and symptom or the patients illness and related to that nature ( severe or mild etc), Nothing but patient comes with what problem and what is its nature is simply known as Nature of presenting illness

Counseling :

Counseling is a discussion with a patient and/or family concerning Patient and family education, Risk factor reduction, Importance of compliance, Instructions for management, Risks and benefits of management, prognosis

When counseling and/or coordination of care dominates (more than 50%) the encounter with the patient and/or family then time shall be considered the key or controlling factor to qualify for a particular level of E/M services.

Time:

Based on evaluation time or time spent with patient we are supposed to take E&M alone based on time there no need to search of other components if the specific time is there

Co-ordination of care:

Same day patient will takes services from the one or more different physicians based on their co-ordination

When counseling and/or coordination of care dominates (more than 50%) the encounter with the patient and/or family then time shall be considered the key or controlling factor to qualify for a particular level of E/M services.

History :

There are some topics involved in History section

HPI   ( History of presenting illness )

ROS ( Review of systems)

Medical history : PFSH

It is further divided in to 3 Histories

SH      : Past social history

PMH   : Past medical history

FH      : Family history

HPI   ( History of presenting illness ) :

It is nothing but the problem that has driven the patient to hospital, Components of HPI are

Location:  Organ name / body parts eg: Head , hand, lower back, etc

Severity :  severity of condition eg patient has mild cough

Timing :  when that condition is coming eg patient has mild cough on night 10 pm

Modifying factor :  factor that affects present condition eg patient take cough syrup but didn’t get relief

Quality :  How the condition appearing eg patient has cough with white phlegm

Duration :  how much time the condition is staying eg patient has cough from night 10 to 12

Context :  what context causing the condition eg patient having cough when he Is drinking ice water, SOB while walking on steps

Associated signs & symptoms:    signs and symptoms of disease eg cough and cold, SOB are the symptoms of asthma

ROS( Review of symptoms ) :

Questions that are asked by provider to the patient related to the body systems

EYES                                 Mild eye pain

ENT                                 Cold

CARDIOVASCULAR         No chest pain

GI                                     No abdominal pain

RESPIRATORY                   Denies cough ,but has sneezing

GENITOURINARY            Denies dysuria

LYMPHATIC                      Denies

MUSCULOSKELETOL       Patient has leg pain but denies muscle pain

ENDOCRINE SYSTEM      No diabetes

NEUROLOGICAL            Denies depression

INTEGUMENTARY           Denies skin related problems

Medical history :

  Medical history denotes past conditions of the patient, It is further divided in to 3 Histories

Past social history  :

It denotes the social behaviour of the patient that means Job, Marital status etc

Eg :   Any drug /alcohol habits

        Working place

       Marital status

Eg  : patient drinks alcohol and uses cigarettes

       Patient currently divorced

       Patient is working for private security agency

PMH   : Past medical history

The conditions those are present in past or those are resolved now or may be present  and also surgeries that the patient  underwent in the past

Eg : patient has PMH cervical caner in 2012 complete hysterectomy done on 2013

Patient has PMH of asthma in childhood

Patient has a leg fracture : reduction done by orthopaedist on 9 months back

FH      :  Family history

This shows conditions that are in patients family

Eg  :  Patient sister Linda is having breast cancer

       Mother had diabetes

       Father has HTN

       Grand mother died due to heart attack at the age of 76

       Sister is having asthma

       Brother is suffering with pneumonia

Physical Examination (PE) :

The examination done by the provider to the patient

Provider visually examine the different parts of organs

It has 2 types of guidelines

1995 guidelines

1997 guidelines

Medical decision making (MDM) :

The diagnosis and treatment or conclusion of the provider towards the patient condition is called as MDM

MDM has major role to code E&M Services

It has 3 categories

No of diagnosis, or treatment options

Amount / complexity of data to be reviewed

Risk of complications /morbidity / mortality

Evaluation and management coding examples:

History:

54 years male patient comes with cough with white sputum, and having shortness of breath while walking on steps and also he has mild wheezing and also runny nose, headache

ROS: patient denies chest pain, no eye irritation, no leg pain, no dysuria, no anxiety, no known drug allergies, has wheezing, no anemia and all are negative

PFSH :

Patient has past medical history of asthma, and he smokes cigarettes, his grand mother have diabetes

Physical Examination:

Psych          :  Alert

Neuro        :  Awake

Lungs         :  No PTA

Heart         :  Normal

Eyes           :  Normal

Genital       :  Normal

Gastro       :  Normal

Endocrine  :  Normal

Assessment:

 Ordered and reviewed the chest x ray patient has severe chronic respiratory failure and patient placed on intubation

and patient has acute asthma exacerbation

Answer :

HPI elements  : 4

ROS :   10

PFSH:  3

For comprehensive we need HPI- 4  ROS-10 PFSH- 3

So this is comprehensive History

The 4 HPI are

Headache                     : Location

White                          : Quality

While walking on steps : Context

Mild                             : Severity

54 years male patient comes with cough with white sputum, and having shortness of breath while walking on steps and also he has mild wheezing and also runny nose, headache

Ros: patient denies chest pain, no eye irritation, no leg pain, no dysuria, no anxiety, no known drug allergies, has wheezing, no anemia and

all are negative

All are negative so ROS is taken 10 i.e. complete

Patient has PMH asthma, PSH smoking, FHX grand mother has DM so we have 3 PFSH

PE : Has 8 so it is comprehensive

MDM:  Respiratory failure Is high risk condition

it is a new problem new to examiner additional work up planned and is on intubation

So MDM is high complex

Totally

History : Comprehensive

PE        : Comprehensive

MDM   : High complex

By the above way we can process the Evaluation and management Coding

There are approximately more than 25 types of E&M Services are there, The most common E&M services are

Office visit

Hospital observation services

Hospital In-Patient services

Consultations

Emergency department

Critical care services

Nursing facility services etc

Evaluation and management CPT codes :

There are certain types of departments in Evaluation and management and there are certain types of codes for the different departments

Evaluation and management cpt codes range will be like this

Office visit – New patient CPT range          : 99202 – 99205

Office visit – Established patient CPT range : 99211 – 99215

Initial observation : 99218- 9920

Subsequent observation : 99224-99226

Observation discharge : 99217

Initial hospital care : 99221 – 99223

Subsequent hospital care : 99231 – 99233

Hospital discharge services : 99238-99238

Observation  same day and discharge : 99234 – 99236

Office consultation : 99241 – 99245

In-patient consultation : 99251 – 99255

Emergency department : 99281 – 99285

Critical care services : 99291 – 99292

These are the evaluation and management codes

What is HCC Coding :

Hierarchical condition category coding is an another type coding which is mainly focus on the process Risk adjustment

HCC Coding can be done by the process of ICD 10 CM Guidelines and Risk adjustment guidelines

Commonly asked questions : 

Conclusion :

Evaluation and management is a process where patient comes with different complaints and gets evaluated by the Physician and Physician provides sufficient management (treatment) for that condition this is known as E&M.

Evaluation and management has 3 key components and 4 contributory factors

History, Physical examination and MDM are the key components, Each components has further divided to levs like PF, EPF, Detailed and comprehensive

There are various types Evaluation and management services those are Outpatient, Inpatient, ED consults etc

Detailed example of Evaluation and management has been discussed Hierarchical condition category coding is an another type coding which is mainly focus on the process Risk adjustment

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