General Surgery Coding Alert - 2022 Issue 1
E/M Coding: Perfect Your ED E/M Coding Skills With 3 Quick FAQs
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Article Overview
This article is for coders, auditors, and clinicians who work with emergency department evaluation and management documentation. It addresses recurring questions about how test orders, history documentation, and limited exam/procedure encounters are reflected in E/M leveling, with emphasis on how documentation supports the reported service. The discussion also points readers to relevant CPT clinical examples and emergency department E/M concepts.
Why This Topic Matters
Emergency department E/M leveling depends heavily on documented work and medical decision making. Understanding how common documentation scenarios are interpreted can help support accurate, consistent reporting and reduce ambiguity during review.
Article Sections
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Introduction
An overview of common emergency department E/M documentation challenges and the types of questions the article addresses.
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FAQ 1: Test Ordered, Not Performed
Discussion of how a physician-ordered diagnostic service that is not completed may be reflected in encounter documentation and medical decision making.
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FAQ 2: Understand HPI Elements
Explanation of how specific history documentation is addressed when present signs, symptoms, or modifying factors are negative or absent.
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FAQ 3: Calculate E/M Elements for Brief Exam and Procedure
A review of a limited emergency department encounter involving a brief exam and a procedure-related visit, with reference to related CPT clinical examples.
What You Will Learn
- How emergency department E/M documentation can affect encounter leveling
- How to think about diagnostic tests that are ordered but not completed
- How history-of-present-illness elements are reflected in documentation
- How brief emergency department encounters are discussed in relation to E/M selection
- How CPT clinical examples are used as reference points in ED E/M review
Who Should Read This
- Emergency department coders
- Medical coders
- Coding auditors
- Clinical documentation staff
- Physicians and other ED providers
Codes Discussed
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