Introduction to EM
EM stands for Evaluation and management:, Evaluation and management (E/M) coding is the use of CPT® codes from the range 99202-99499 to represent services provided by a physician or other qualified healthcare professional.
As the name E/M indicates, these medical codes apply to visits and services that involve evaluating and managing patient health. Examples of E/M services include office visits, hospital visits, home services, and preventive medicine services.
Medicare, Medicaid, and other third-party payers accept E/M codes on claims that physicians and other qualified healthcare professionals submit to request reimbursement for their professional services.
E/M service codes also may be used to bill for outpatient facility services. Facilities and practices may use E/M codes internally, as well, to assist with tracking and analyzing the services they provide. E/M services are high-volume services. Even small E/M coding mistakes can cause major compliance and payment issues if the errors are repeated on a large number of claims. To ensure accurate reporting and reimbursement for these services, those involved in the coding process need to stay up to date on E/M coding rules.
EM Components
EM has following components:
History
Exam
Medical Decision Making
Counselling
Coordination of care
Nature of presenting problem (NPP)
Time
History: This involves a review of the patient’s medical history, including symptoms, illnesses, operations, etc.
Examination: A physical examination of the patient to assess their health status.
Medical Decision Making (MDM): This involves the process of diagnosing a patient’s condition and deciding on a treatment plan.
Counseling: This includes discussions with the patient about their condition, prognosis, risks, benefits of treatment, etc.
Coordination of care: This involves arranging further healthcare services for the patient, such as referrals to specialists.
Nature of presenting problem: This refers to the severity and complexity of the patient’s problem(s).
Time: The amount of time spent with the patient during their visit.
Each component plays a crucial role in determining the level of E/M service provided to a patient.
Key Components:
Out of these 7 components, 3 are called key components, because level used to be decided based on these 3, which are as follows:
History
Exam
MDM
Other 3 are called contributory components:
Counseling
Coordination of care
Nature of presenting problem
Last one, i.e., Time is controlling factor.
The level can be decided based on these key components or Time which ever gives the highest level.
How E/M evolved from 2020 to 2023
Below are the updates from 2024
It includes
Time range update in office visit codes
Thresholds was changed for Nursing facility codes
New code was added for pelvic Examination
Length of stay requirement was added for same day admit and discharge patient for non-Medicare payor as well.
FS modifier, billing provider can be one who gives the substantive portion of MDM or time, it was time alone used for deciding earlier
G2211 codes added
2024 EM updates summary
Time range has been removed from office codes:
In 2023, a conflict arose between the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) regarding the time requirements for prolonged service codes. The AMA used CPT code 99417 for prolonged service, while CMS used G2212.
Both codes required the completion of a full 15 minutes for reporting. The AMA calculated this 15-minute period from the lower time limit of 99205, which has a range of 60 to 74 minutes. In contrast, CMS calculated the 15-minute period from the upper limit of the E/M code.
This difference led to confusion in coding. For instance, if a provider spent 75 minutes with a patient in an office setting, according to AMA guidelines, the encounter could be coded as 99205 and 99417. However, according to CMS guidelines, G2212 should be used if 15 minutes were completed beyond 74 minutes, which means here it would be only coded with 99205. To code 99205 + G2212, the total time spent should be 89 minutes, including 15 minutes beyond the initial 74 minutes.
To address this confusion, the AMA removed the time range requirement for prolonged service codes in 2024. This change simplifies the coding process and reduces confusion for medical coders, ensuring that providers can accurately report the time spent on patient care.
Now, If a provider spends 75 minutes, it would be coded with 99205 (60 minutes would be covered) and 99417 (remaining 15 minutes) according to AMA, while 99205 (60 minutes) and G2212 (remaining 15 minutes) will be used according to CMS.
Time Thresholds for Nursing Facility Care Codes
The nursing facility care codes 99306 (Initial nursing facility care, per day) and 99307 (Subsequent nursing facility care) have undergone revisions.
The time thresholds for these codes have been increased by five minutes:
99306: The new threshold is 50 minutes.
99307: The revised threshold is 20 minutes
New Code: +99459: - Pelvic examination
CPT® 99459 – pelvic exam, is a direct practice expense only code that may be billed with E/M services when practitioners are providing a pelvic exam to patients during an E/M service.
During an evaluation and management service, the provider conducts a pelvic exam on the patient. This examination may involve inspecting both the external and internal genitalia. For female patients, the provider might use a speculum to examine the cervix and vagina and collect a Pap smear specimen. Additionally, the provider may manually assess the size and position of pelvic organs.
Parenthetical instructions: Use 99459 in conjunction with 99202, 99203, 9204, 99205, 99212, 99213, 99214, 99215, 99242, 99243, 99244, 99245, 99383, 99384, 99385, 99386, 99387, 99393, 99394, 99395, 99396, 99397.
Time range for same day admit and Discharge:
AMA and CMS had followed the different time ranges