CPT Codes Guide - Healthcare

E&M Codes

Channagangaiah

E&M Codes – Evaluation and Management Codes

We can select the appropriate level of E&M codes based on the following:

  • Key Components (New Patient – 3/3 and Established Patient –  2/3)
  • Based on time of counseling

Key components of E&M codes

The 3 important key components of E&M codes are:

  1. History of the Patient
  2. Physical Exam
  3. Medical Decision Making

Based on these key components, we assign the E&M codes. Each component expressed with different terms to select the appropriate E&M code:

  1. History of the patient:
  • Problem focused
  • Extended problem focused
  • Detailed
  • Comprehensive

 

  1. Physical Exam
  • Problem focused
  • Extended problem focused
  • Detailed
  • Comprehensive

 

  1. Medical Decision Making
  • Straight Forward
  • Low Complexity
  • Moderate Complexity
  • Higher Complexity

When selecting the E&M codes, if all the 3 key components are meeting or matching then we can select the appropriate E&M Code.

How to select the level of E&M codes for New Patient?

Let us see with examples on how to select the appropriate level for New Patient E&M codes (3/3):

Assume new patient visits the doctor office for treatment.

Example 1:

After reviewing the medical records assume the following 3 key components are documented:

  1. History (H) – Problem Focused
  2. Physical Exam (PE) – Problem Focused
  3. Medical Decision Making (MDM) – Straight Forward

PF – 99201

PF – 99201

SF – 99201/99202

If it’s a new patient 3/3 key components should meet. In the above example all the 3 key components falls under 99201, hence we can report 99201 E&M code.

Note: If counseling leads more than 50 percent, than time shall be considered to qualify for the specific level of E&M code.

 

Example 2:

Suppose if all the 3 key components are not matching, then how to select the appropriate E&M code.

After reviewing the medical records, now assume the following 3 key components are documented:

  1. History (H) – Detailed
  2. Physical Exam (PE) – Extended Problem Focused(EPF)
  3. Medical Decision Making (MDM) – Moderate Complexity(MC)

In the above example the 3 key components are not at the same level

Detailed – 99203

EPF – 99202

MC – 99204

If it’s a new patient visit, when the levels are not meeting, then code with the lowest one.

In this case, we have to select the lowest CPT code that is 99202.

Note: If counseling dominates more than 50%, than time shall be considered the key factor to qualify for the particular level of E&M service.

 

Example 3:

Consider one more example with same scenario but with different key components,

 

  1. History (H) – Detailed
  2. Physical Exam (PE) – Extended Problem Focused(EPF)
  3. Medical Decision Making (MDM) – Low Complexity(LC)

Detailed – 99203

EPF – 99202

Low Complexity – 99203

In this 2 is matching, but still we code with the lowest one that is 99202.

Note: If counseling dominates more than 50%, than time shall be considered the key factor to qualify for the particular level of E&M service.

 

Example 4:

  1. History (H) – Extended Problem Focused(EPF)
  2. Physical Exam (PE) – Extended Problem Focused(EPF)
  3. Medical Decision Making (MDM) – Straight Forward(SF)

EPF – 99202

EPF – 99202

SF – 99201/99202

In this case the CPT 99202, all the 3 key components are meeting. Hence we code with E&M code 99202.

Note: If counseling dominates more than 50%, than time shall be considered the key factor to qualify for the particular level of E&M service.

 

How to select the E&M codes of Established patient?

Now let us see with examples on how to select the appropriate level for Established Patient E&M codes (2/3):

Now assume Established patient visits the doctor office for treatment.

Example 1:

  1. History (H) – Problem Focused(PF)
  2. Physical Exam (PE) – Extended Problem Focused(EPF)
  3. Medical Decision Making (MDM) – Moderate Complexity(MC)

PF – 99212

EPF – 99213

MC – 99214

All three key components are at different level. If it is an established patient, we will select the 2nd lowest E&M code by dropping the 1st lowest E&M code.

In the above example 1st lowest E&M code is CPT 99212 and second lowest E&M code is CPT 99213. Hence as per guidelines we drop the 1st lowest code and select the second lowest code that is CPT 99213.

Note: If counseling dominates more than 50%, than time shall be considered the key factor to qualify for the particular level of E&M service.

Example 2:

  1. History (H) – Extended Problem Focused(EPF)
  2. Physical Exam (PE) – Extended Problem Focused(EPF)
  3. Medical Decision Making (MDM) – Moderate Complexity(MC)

EPF – 99213

EPF – 99213

MC – 99214

Answer is CPT 99213

Example 3:

  1. History (H) – Comprehensive
  2. Physical Exam (PE) – Detailed
  3. Medical Decision Making (MDM) – Low Complexity(LC)

Comprehensive – 99215

Detailed – 99214

Low Complexity – 99213

Answer is CPT 99214

Note: If counseling dominates more than 50%, than time shall be considered the key factor to qualify for the particular level of E&M service.

 

Based on the Place of Service (POS) – place where the service provided, we are going to select the E&M codes.

Some of the important E&M codes based on place of service which are frequently used is listed as follows:

  1. Office visit/Out Patient E&M Codes
  2. New patient E&M codes (3/3)
  • 99201
  • 99202
  • 99203
  • 99204
  • 99205

 

  1. Established Patient E&M Codes (2/3)
  • 99211
  • 99212
  • 99213
  • 99214
  • 99215

 

  1. Hospital Inpatient E&M Codes
  2. Initial Hospital Care E&M codes (3/3)
  • 99221
  • 99222
  • 99223

 

  1. Subsequent Hospital Care E&M codes (2/3)
  • 99231
  • 99232
  • 99233

 

  1. Hospital Discharge Services E&M Codes
  • 99238
  • 99239

 

  1. Observation or Inpatient care E&M Codes
  2. Same day admission & discharge E&M codes(3/3)
  • 99234
  • 99235
  • 99236

 

  1. Different day admission & discharge E&M codes
  2. Intial Observation care(3/3)
  • 99218
  • 99219
  • 99220

 

  1. Subsequent Observation Care(2/3)
  • 99224
  • 99225
  • 99226

 

  • Observation care Discharge Services
  • 99217

 

  1. Consultation E&M Codes
  2. Outpatient Consultation codes (3/3)
  • 99241
  • 99242
  • 99243
  • 99244
  • 99245

 

  1. Inpatient Consultation codes (3/3)
  • 99251
  • 99252
  • 99253
  • 99254
  • 99255

 

  1. Nursing Facility Services
  2. Initial Nursing Facility Care(3/3)
  • 99304
  • 99305
  • 99306

 

  1. Subsequent Nursing Facility Care(2/3)
  • 99307
  • 99308
  • 99309

 

  1. Nursing Facility Discharge Services
  • 99315
  • 99316

 

  1. Other Nursing Facility Services(3/3)
  • 99318

 

  1. Domiciliary, Rest home, or Custodial care services
  2. New patient(3/3)
  • 99324
  • 99325
  • 99326
  • 99327
  • 99328

 

  1. Established patient(2/3)
  • 99334
  • 99335
  • 99336
  • 99337

 

  1. Home Services
  2. New patient(3/3)
  • 99341
  • 99342
  • 99343
  • 99344
  • 99345

 

  1. Established patient(2/3)
  • 99347
  • 99348
  • 99349
  • 99350

 

  1. Prolonged Services E&M Codes (Add on codes)
  • +99354
  • +99355
  • +99356
  • +99357