ED Coding & Reimbursement Alert - 2012 Issue 20
E/M Coding: Translate the Alphabet Soup of E/M Coding With These 5 FAQs
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Article Overview
This article explains core evaluation and management (E/M) documentation concepts in a question-and-answer format. It is aimed at coders, billers, and clinicians who want to better understand how history, review of systems, past medical/family/social history, exam guideline differences, and medical decision-making affect E/M reporting. The discussion is framed around commonly used CMS and CPT-based guidance and highlights why documentation quality matters for selecting the appropriate level of service.
Why This Topic Matters
E/M coding is a frequent source of claim scrutiny and documentation variation. Understanding the major components discussed here helps practices evaluate whether their records support the reported level of service and follow payer expectations.
Article Sections
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How Do We Calculate HPI?
Explains the role of history of present illness in E/M documentation and discusses its relationship to different levels of outpatient service reporting.
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What Are the Different ROS Levels?
Covers review of systems as part of the history component and outlines the general categories of ROS documentation discussed in the article.
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Does Provider Have to Capture New PMFSH Every Time?
Discusses past medical, family, and social history documentation and the broad levels of detail referenced for E/M history assessment.
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What are the 1995 vs. 1997 Guideline Exam Differences?
Compares the two E/M documentation guideline frameworks and describes their differing approaches to the exam component.
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Does Overall Risk Determine MDM Level?
Summarizes medical decision-making as an E/M component and the broad factors used to evaluate the level of complexity and risk.
What You Will Learn
- The major components used to evaluate E/M documentation
- How history-related elements fit into outpatient E/M reporting
- The general categories of review of systems documentation
- How past medical, family, and social history is addressed in E/M records
- The broad differences between the 1995 and 1997 E/M exam guidelines
- The main elements considered in medical decision-making
- Why documentation quality affects the reported level of service
Who Should Read This
- Medical coders
- Medical billers
- Physicians and other clinicians
- Compliance and documentation staff
- Revenue cycle teams
Codes Discussed
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