E/M Documentation and Coding Articles and Resources

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2024 CPT Coding Updates...Are You Ready?

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Each year the CPT coding updates are published and coders nationwide rush to ensure they understand the impact they will have on their workflow and organization in general. For the first time in three years, changes to the Evaluation and Management (E/M) codes are minimal. However, the Medicine section, specifically the codes and guidelines for reporting COVID-19 vaccines have significant changes and unfortunately they are not reflected in that shiny, new CPT codebook you just purchased.

Reporting Evaluation & Management (E/M) Services with Wellness or Preventive Medicine Service Encounters

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Preventive medicine services, initial preventive physical examinations (IPPE), and the annual wellness exam consist of many required performance and documentation criteria to ensure ample patient history is obtained and charted in an effort to reduce the risk of disease and disease progression. Although not planned, these encounters often include a problem-oriented visit as well, requiring the coder to know how to separate out the preventive service from the problem-oriented encounter for coding and billing.

Medicare Guidance Changes for E/M Services

by  Wyn Staheli, Director of Content - innoviHealth

2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....

Can We Score Interpretation of an EKG Towards E/M Medical Decision Making?

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

When EKGs are performed in the facility setting or even in the physician's office, what are the requirements for reporting the service and who gets credit for scoring data points for Evaluation and Management (E/M) medical decision making (MDM)? Let's take a look at a few coding scenarios related to EKG services to get a better understanding of why this can be problematic.

COVID Code Consolidation, Spanish-Language Options, RSV Highlight Looming Code Changes

by  Angela Jordan, CPC, CPMS, COBGC

This past Friday, the American Medical Association (AMA) announced the much-anticipated release of the 2024 CPT® code set; however, there’s a bit of a catch.  The code set is only available on the AMA’s Intelligent Platform to those in the healthcare industry that are licensed to use the CPT...

Documenting and Reporting Postoperative Visits

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Sometimes we receive questions regarding documentation requirements for specific codes or coding requirements and we respond with information and resources to support our answers. The following question was recently submitted: Are providers required to report postoperative services on claims using 99024, especially if there is no payment for that service? What documentation is required if you are reporting an unrelated Evaluation and Management (E/M) service by the same physician during the postoperative period? 

When Is a Shared Visit Not a Shared Visit?

by  David M. Glaser, Esq.

Can you do a “shared visit” in a physician clinic, site of service 11? The most common answer to this question seems to be “no,” and while that is technically correct, it is so misleading that it is effectively entirely wrong. To understand this confusion, we need to dig...

Answers to Evaluation & Management Questions From Webinar Attendees

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Following every Evaluation & Management (E/M) webinar, we receive questions from attendees reflecting the specific circumstances they have identified within their individual organizations. We wanted to take some time to address some individual questions for the benefit of others who have some of the same questions. These questions are related to scoring Medical Decision Making (MDM) in the E/M coding guidelines.

Finding Patterns of Complexity in the Medical Decision Making (MDM) Table

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Changes to the Medical Decision Making (MDM) Table in 2023 reflect the work performed in the facility setting in addition to the work involved in Evaluation and Management (E/M) scoring in other places of service. Taking the time to really look closely at the MDM Table and identify patterns in wording and scoring helps coders to understand scoring in an easier way.

E/M Scoring Questions

by  Wyn Staheli, Director of Content - innoviHealth

Evaluation and Management visits are often the “bread and butter” of an organization. Thus, correctly scoring encounters is essential to ensuring proper reimbursement. The element of “Risk” is only one of the three elements of Medical Decision Making (MDM), but understanding what is meant by all the definitions within each element is critical.

Seven Reasons to Standardize Medical Records

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

The standardization of medical records offers numerous benefits for healthcare systems, providers, and patients. By ensuring interoperability, improved workflows, better patient safety, supporting research endeavors, and optimizing resource allocation, standardized records contribute to improved efficiency, quality of care and especially patient outcomes. Here are seven reasons to standardize medical records.

Advancements in Coding Hospital Observation Care Services in 2023

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Hospitals are increasingly adopting innovative solutions to improve patient care and optimize processes and many of these solutions follow immediately the recent CPT and Medicare coding changes.  In 2023 coding of hospital observation care services underwent significant changes enabling healthcare providers to accurately document and bill for the sick or injured patient that requires a higher level of medical services between the emergency room care and hospital admission. This article explores the key changes in coding hospital observation care services and their impact on healthcare delivery.

Be Aware — Emergency Department Visits Under OIG Scrutiny

by  Wyn Staheli, Director of Content - innoviHealth

Every year the Department of Health & Human Services Office of Inspector General (OIG) creates an official work plan giving everyone a heads up as to what they are going to be reviewing. The 2022 Work Plan stated that they would be reviewing claims for Evaluation & Management services provided in an emergency department (ED) setting.

Identifying the Components of a High-Risk Evaluation and Management Service

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

How comfortable are you with selecting a high-level Evaluation and Management service and how often do you see high-risk E/M codes reported? In 2023, the CPT coding guidelines for E/M coding changed drastically, moving from a 3-key component scoring system to determining the final code using either time or medical decision making (MDM), but accurately scoring and having confidence in the selection of a high-level E/M service remains challenging.

The Perils of E&M Codes and Insurance

by  Knicole C. Emanuel, Esq.

- ... Continue reading the article at RACmonitor → This article originally published on May 31, 2023, by RACmonitor....

Five Documentation Habits Providers Can Use/Implement to Improve Evaluation & Management (E/M) Scoring

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Provider education on E/M coding updates is vital to the success of any organization, but how do you whittle down the massive information into bite-sized pieces the providers can learn in just a few minutes? Check out the five steps we have identified to teach providers in just a few minutes that can significantly impact and improve coding outcomes.

Focusing on the Diagnosis Instead of the Problems Addressed Can Impact E/M Scores

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Many diagnosis code descriptions contain language such as severity or complexity, acute on chronic, and others that may mislead a coder into thinking they are coding a condition that is more severe than it really is. How can we be certain we are scoring the patient's problems instead of their diagnoses?

7 Measures Developed by the HHS Office of Inspector General (OIG) to Identify Potential Telehealth Fraud

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

A recent review of telehealth services reported in Medicare claims data during the pandemic where these seven measures for identifying suspected fraud, waste, and abuse were applied, revealed more than a thousand Medicare providers potentially committed fraud during this period. What are the measures the OIG applied during their review, and how will that impact future telehealth guidelines moving forward?

Facility Outpatient E/M Coding

by  Wyn Staheli, Director of Content - innoviHealth

Reporting outpatient E/M services in a facility setting is a little different than other outpatient services. It is important to follow payer guidance. Novitas has provided some guidance on which codes to report based on the type of service provided. They have an FAQ which covers both emergency department (99281-99285, G0380-G0384) and clinic visits.

2023 E/M Changes — Are You Sure You are Compliant?

by  Raquel Shumway

Have you addressed all of the 2023 E/M Changes including the new changes added in March? Have you conducted a self-audit and trained your staff on these changes? Find-A-Code has tools available to help you make sure you are in compliance with these new changes.

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Select the title to see a summary and a link to the full webinar information.  some webinars require a subscription to view.

2023 Evaluation and Management Question and Answer 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Thursday @ 10:15 AM PST, 11:15 AM MST, 12:15 PM CST, 1:15 PM EST Get your burning E/M questions answered with this amazing webinar on October 12, 2023. We receive questions all the time, so we took some of the questions that were submitted to us in relation to E/M services and compiled them into this informative webinar covering how to bill resident services, count labs ordered versus reviewed, handling "laundry list" assessment/plan documentation, and more.

A Deep Dive into the 2023 MDM Table 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

2023 brought additional changes to the Medical Decision Making (MDM) table. Even more E/M services are now being scored on either MDM or time. This means that a comprehensive understanding of each of the elements of MDM is critical to ensuring proper code selection. Join us for this informative webinar led by an auditor who regularly reviews these types of claims and knows where the pitfalls are. Learn the differences between definitions and listen to examples of the different levels of each element of MDM.

Auditing EM Services Using the FAC EM Calculator Tool 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Medical decision-making (MDM) is a critical part of code selection for evaluation and management services. It is highly recommended that organizations take time to perform internal audits of billed E/M services to ensure that all required elements are met for the level of MDM reported. Join us for this informative webinar which goes over the different elements of MDM as well as how to use Find-A-Code's Calculator tool to perform your own internal audit.

Formatting & Documentation Best Practices for Evaluation & Management Services 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Join us to learn 7 reasons for standardizing your medical records. We include ways to format the medical record, which can be helpful when documenting the visit. A standard format can provide benefits, such as reminders to record pertinent information, allow for the exchange of PHI between providers, and reduce incomplete or inaccurate data which can lead to inaccurate coding. It can also streamline your workflow, which saves time and money as well as providing more accurate diagnosis and better treatment for patients.

Medical Decision Making | What it is and What it Means to You 

by  Ron Short, DC MCS-P CPC

Presented by Ron Short DC, MCS-P, CPC July 11, 2023 Tuesday @ 10:15 AM PT, 11:15 AM MT, 12:15 PM CT, 1:15 We are hearing a lot about Medical Decision Making (often abbreviated as MDM) now that it is one of the only two ways to determine the appropriate Evaluation and Management code level. In this webinar Dr. Short will show you:  What is Medical Decision Making  When does Medical Decision Making occur  How Medical Decision Making is important to you  How to use Medical Decision Making to your advantage You can obtain the notes for this webinar by subscribing to my e-mail updates at http://www.chiromedicare.net/mailing-list-signup/ (the link to the notes will be in the final welcome e-mail) or by following the link provided in my e-mail update. They will be available by the Monday prior to the webinar presentation.

Documentation Best Practices for Emergency Department Services 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Emergency Department E/M services were significantly revised beginning in 2023. Key components as we knew them are gone and observation services were also changed. Join us for this informative webinar to learn what needs to be done to ensure that your documentation and coding practices are current and compliant.

Looking Closer at High Risk EM Medical Decision Making 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Thursday @ 10:15 AM PST, 11:15 AM MST, 12:15 PM CST, 1:15 PM EST Join us for a deep dive into the Evaluation & Management element of "Risk". Learn more about the differences between complications, morbidity, and mortality and how that drives coding. What does it really take for an encounter to be considered "High risk?"

Setting Goals that Prove Medical Necessity in Your Records 

by  Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow

'Reduce pain" may be a real goal of chiropractic care, but is it enough? While you may want to help your patients to reduce their pain, goals need to focus on what kinds of functions are affected by that pain. Does it keep the patient from sleeping, from sitting at a desk, from washing their hair when in the shower? Learn how to create goals that are easy to defend and use to justify ongoing treatment in this fun-filled webinar by Dr. Evan Gwilliam, a Certified Professional Medical Auditor.

Diagnosis vs Problem EM MDM 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Understanding the differentiation of a "problem" versus a "diagnosis" is essential to proper Evaluation and Management scoring. Join us as we discuss about how these elements play into medical decision-making and what needs to be documented to support E/M complexity.

Keeping up to date on reporting changes... 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Properly reporting split or shared patient encounters can be tricky. The CPT codebook just began defining this type of encounter and the 2023 Medicare Physician Fee Schedule Final Rule included some changes. Tune into this informative webinar to ensure that you are doing things the right way.

Use the Right Modifiers for Chiropractic Billing 

by  Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow

Do you really know when to use the 59 modifier? What about the AT? There are relatively few modifiers to consider when it comes to chiropractic billing and coding, but some payers have their own rules and it can be tricky to know when to use one modifier and not another. In this exciting webinar, Dr. Evan Gwilliam, a certified coder, will clear up all the questions you have about the modifiers you need to consider.

The Differences between Medicare and CPT, Reporting Prolonged Services 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Prolonged services reporting has changed for 2023. Tune into this informative webinar to review the changes including coding examples for payers following CPT guidelines as well as Medicare. Be sure you are prepared and that your documentation meets individual payer requirements.

Current Terminology - 2023 Annual Update Summary

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Be sure you are ready for 2023 with this review of the upcoming coding and reimbursement updates for 2023. This informative webinar discusses changes to CPT codes and guidelines including a summary of the changes to E/M services and an overview of changes to other CPT categories.

2023 CPT Evaluation & Management Updates 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Get ready for the 2023 CPT Evaluation & Management (E/M) changes with this informative, free webinar! Now is the time to find out about the changes to these commonly used codes which include the main Introductory guidelines as well as changes to many other categories including Consultations,…

Dealing with the Little Coding Conundrums 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Do Minor Procedures Feel like Major Work? 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Reporting Telemedicine Services by Aimee Wilcox 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Split/Shared & Incident-to Evaluation and Management Changes for 2022 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Chiropractic Documentation: The Subjective Element 

by  Ron Short, DC MCS-P CPC

The Subjective element of S.O.A.P. is where we document what the patient tells us.  But what is the best way to gather this information?  In this webinar Dr. Ron Short will review the guidelines for the subjective element and explain the best way to gather information from the patient.&…

Scoring E/M Services Based on MDM 

by  Wyn Staheli, Director of Content - innoviHealth  and  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Chiropractic Documentation: The S.O.A.P. Format and Additional Information 

by  Ron Short, DC MCS-P CPC

We have all heard of the S.O.A.P. format for our documentation. But what does each element mean and what additional information do we need in our documentation? In this webinar Dr. Ron Short will review the S.O.A.P. documentation format and discuss what additional information you need document. In…

Chiropractic Manipulative Treatment: Coding and Documentation 

by  Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow

The most commonly used procedure in chiropractic is the chiropractic adjustment, also known as chiropractic manipulative treatment or CMT. There are nuances to the CPT and ICD-10 codes and Medicare guidelines that must be mastered by any chiropractor hoping to find success when creating their…

AMA Announced New E/M Guideline Changes on March 9, 2021 Retroactively Effective to January 1, 2021 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Evaluation & Management Coding Rules are Changing in January - Is Your Organization Ready? 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Preparing for E&M Changes in 2021 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

E/M and the Organ Systems Part 2 of 2 

E/M and the Organ Systems Part 2 of 2

E-M and the Organ Systems (Part 1) 

E-M and the Organ Systems (Part 1)

Coding Auditing Evaluation and Management and 2019 

Coding Auditing Evaluation and Management and 2019

Evaluation and Management Coding and Auditing 

by  Find-A-Code™

Are you responsible for selecting or reviewing Evaluation and Management service levels? Do you wonder how well you know the rules and how to apply them? Join Aimee in this webinar to review and then applly the rules of E/M coding. She will also do a live demonstration of the new Find-A-Code E/M Calculator Tool to assess the level of E/M service for two office visits, one new (99201-99205) and the other established (99212-99215).

Coding Auditing Inpatient Evaluation and Management — A Hands-On Experience 

by  Find-A-Code™

Do your providers perform and report Evaluation and Management (E/M) services in the inpatient setting? Does the documentation match with the services being billed, or does it fall short? Join Aimee for a hands-on audit of an inpatient E/M service and get an idea of the information and documentation needed to correctly code inpatient E/M services.

The Proper Way to Report Modifiers 

by  Find-A-Code™

Modifier 25 has long been a coding conundrum and an auditor's gold mine. Don't risk take-backs, penalties, or accusations of fraud and abuse. Join Aimee in this webinar on how to properly report modifier 25 and have confidence in your code reporting.

Using Find-A-Code's New Evaluation and Management Calculator Tool 

by  Find-A-Code™

Using Find-A-Code's New Evaluation and Management Calculator Tool

Evaluation and Management Self Audit for Beginners, Part 4: Medical Decision Making 

by  Find-A-Code™

Evaluation and Management Self Audit for Beginners, Part 4: Medical Decision Making

Evaluation and Management Self Audit for Beginners, Part 3: Examination 

by  Find-A-Code™

Evaluation and Management Self Audit for Beginners, Part 3: Examination

Evaluation and Management Self Audit for Beginners, Part 2: History 

by  Find-A-Code™

Evaluation and Management Self Audit for Beginners, Part 2: History

Evaluation and Management Self Audit for Beginners, Part 1: Fundamentals 

by  Find-A-Code™

Evaluation and Management Self Audit for Beginners, Part 1: Fundamentals

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