E/M Code Analyzer

Evaluation and Management (E/M) codes are a subset of the Current Procedural Terminology (CPT) code set, established and copyrighted by the American Medical Association (AMA). E/M codes are used to report encounters with healthcare professionals using a variety of methods (e.g., direct patient contact, non-face-to-face, telemedicine, telephone) and in a variety of settings (e.g., hospital, office, home, skilled nursing facility).

Selecting the correct level of E/M service to be reported is accomplished with the proper application of specific guidelines either published in the CPT codebook or published by a third-party payer (e.g., Medicare, commercial plans) within a specific policy or guideline. This information is often included as part of provider contracts. In addition to following payer policies, all E/M code selection is first determined by the following:

• location where encounter took place (e.g., office, hospital),
• the patient’s status (new, established),
• type of service (consultation, critical care, observation), and
• the intensity and complexity of the patient’s condition and management options. Intensity and complexity are determined by the details of the documentation of the encounter note located within the medical record.

E/M services are some of the more commonly audited services. Providers can maximize payment and potentially avoid audit pitfalls by providing adequate and descriptive details within the medical encounter note and appropriately determining the overall level of service based on medical necessity.

On January 1, 2021, major changes were made to the E/M category Office or Other Outpatient E/M Services (99202-99215). These changes have been incorporated into this calculator. It is anticipated that additional guideline changes will be published in the future and Find-A-Code will continue to update the calculator to incorporate any new guidelines as they are published.

The Medicare 1995 and 1997 E/M coding guidelines are well known and followed by many payers. As Medicare has agreed to follow the new CPT guidelines for 99202-99215, the Medicare 1995 and 1997 guidelines are no longer applicable for these services beginning in 2021. However, the calculator includes the option to score the service based on those 1995 or 1997 guidelines for the years prior to 2021, if needed.

While time, MDM, or the individual components may determine the overall level of an E/M service, the overarching criterion for determining the final level is medical necessity, which may result in lowering a score that would otherwise qualify based on time but, due to medical necessity, a higher level of service is not supported.

The E/M code calculator is a great training tool for students, coders, auditors, and especially providers. Please note that it does not store any patient health information (PHI) which allows the user to enter PHI into the auditing report notes section and either save it as a PDF on their own systems or print the document for internal purposes. Once completed, all entered data will automatically be deleted from the tool and our system permanently. That also means if you forget to print or save, the information will be gone upon leaving the page or exiting the tool.

This tool calculates E/M codes for:

• Office (new patient) 99202-99205
• Office (established patient) 99211-99215
• Office Consultation (new/established) 99241-99245
• Hospital (initial) 99221-99223
• Hospital (subsequent) 99231-99233
• Hospital Consultation 99251-99255

As of 2021, there are 26 subcategories of E/M services and Find-A-Code plans to continue to expand this calculator tool to include other subcategories in the future. We hope you enjoy using the tool and if you have any questions or recommendations for improvement, please reach out to information@innovhihealth