Welcome to the AASM Coding Education Program. Our fourth module will address evaluation and management coding in the office or other outpatient setting. Our learning objectives for this module are identify key terminology used in evaluation and management coding in the office or other outpatient setting. Identify evaluation and management codes used in the sleep center. Describe the 2021 guidelines for evaluation and management coding. Evaluation and management codes are CPT codes that describe services, typically office visits, provided by physicians. Evaluation and management is abbreviated as E&M. For these services, the patient comes to the physician with a reason for the visit, such as an illness or injury. This reason for the visit is called the chief complaint. The physician will take the patient's history and also perform an examination. The physician then determines a course of care or may decide to modify an existing course of care for the patient. Based on the patient's condition, the patient may require a test or service in addition to the office visit. For sleep centers, E&M services are typically office visits to assess the patient for a sleep disorder or determine the effectiveness of a treatment for a sleep disorder. In this instance, the physician may decide that a patient requires a sleep study, which will require a separate procedure code. E&M codes are CPT codes, which are 5-digit codes. The first two digits in all E&M codes are 9-9. This puts E&M codes at the very end of the list of all CPT codes, however, because E&M codes are used so frequently, the AMA, the American Medical Association, has chosen to organize the codebook out of numerical order. E&M codes are found at the very beginning of the CPT codebook immediately following the introductory text. Sleep centers use two ranges of E&M codes to code for sleep center office visits. These include the new patient office visit code range 99202 through 99205 and the established patient office visit code range of 99211 through 99215. The appropriate E&M code is selected based on the extent or level of the service provided to the patient. Level of service is a term used to describe the extent and type of treatment provided during a physician's service. For E&M services, higher code numbers in a given range of E&M codes translate to higher levels of service. The codes with a higher level of service are also assigned higher reimbursement. Office visits are not the only E&M codes. There are a number of other E&M services that are not typically used in the sleep center. These include codes for hospital visits, consultations, emergency department visits, critical care services, nursing facility services, home services, preventative medicine services, newborn care services, and many more. A full list of the E&M codes can be found in the CPT codebook. In E&M coding, there are new patients and established patients. A new patient is a patient who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice within the past three years. An established patient is a patient who has received professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice within the past three years. For example, neurologists within the same practice may refer patients to one another. Once a patient is seen by one of the neurologists, he or she is no longer considered a new patient even if he or she is seen by a different neurologist in the practice. Due to the complexity of E&M coding and the difficulty in assigning appropriate codes, documentation guidelines were developed in 1995 and 1997. As of January 1, 2021, several changes to the E&M coding for office or other outpatient visit guidelines were adopted and implemented by both the American Medical Association and the Centers for Medicare and Medicaid Services as were the original guidelines. Several of the key changes include the following. First, although history and physical exam are still performed and documented, they are no longer used to determine the appropriate level of service or for code selection. Second, the appropriate level of service is now determined by either medical decision making or the total time. The total time is for E&M services performed on the date of the encounter. Also, CPT code 99201 for new patients has been deleted from the code set. When determining the level of service based on medical decision making or MDM, there are several criteria that should be considered including the number and complexity of problems addressed, the amount and complexity of data to be reviewed and analyzed, risk of complications and or morbidity or mortality of patient management, and the number of MDM elements met. When considering using total time to determine the level of service, it's important to note that the total time on the date of the encounter has specific definitions to address overlap concerns. Codes may be selected using total time regardless of whether the majority of the visit was spent on counseling. Additionally, both face-to-face and non-face-to-face patient activities can be used to calculate total time. New patient E&M codes in the code range 99202 through 99205 include descriptors that outline the key components necessary to use each code. For a new patient, all of the key components in the physician's documentation must meet or exceed the requirements of the code descriptor in order to qualify for the level of service. Code 99202 is the lowest code available for new patient office visits. This code should be selected when the level of medical decision-making is considered straightforward or when using time for code selection, 15 to 29 minutes of total time were spent towards the encounter on the day of the visit. To determine the appropriate level of medical decision-making, three elements are considered as shown in the MDM table for 99202. To be considered straightforward, two of the three elements should fit within the criteria in the MDM table shown here. In terms of problems addressed, it is considered straightforward if it is one self-limited or minor problem, data reviewed should be minimal or there should be no data, and there should be minimal risk of morbidity from any testing or treatment implemented. Code 99203 is appropriate for a new patient office visit when the level of MDM is considered low. If using time, code 99203 is appropriate if 30 to 44 minutes of total time was spent toward the visit on the day of the encounter. For code 99203, the level of MDM should again be low. That means it should meet at least two out of the three elements listed in the table. For problems addressed, low would mean two or more self-limited or minor problems, one stable chronic illness, or one acute uncomplicated illness or injury. For data analyzed to be considered low, it must meet the requirements of at least one of the two categories to follow. For Category 1, any combination of two from the following must be met. A review of prior external notes from each unique source, review of the results of each unique test, and ordering of each unique test. The next category, Category 2, is Assessment Requiring an Independent Historian. There should be low risk of morbidity from additional diagnostic testing or treatment during the visit to meet a low level of MDM. Next is code 99204. This code should be selected for a new patient office visit where the level of MDM is considered moderate. If using time for code selection, this code is appropriate if 45 to 59 minutes of total time were spent on the date of the encounter. This table outlines the three elements required to meet a moderate level of MDM. To report code 99204, the visit would need to meet two out of three elements listed in this table. For element 1, a moderate level would be one or more chronic illnesses with exacerbation, progression, or side effects of treatment, or two or more stable chronic illnesses, or one undiagnosed new problem with uncertain prognosis, or one acute illness with systemic symptoms, or one acute complicated injury. The second element, data to be reviewed and analyzed, would have to meet at least one of the three categories listed. Category 1 needs to be three points from the following list. Review of prior external notes from each unique source, review of results of each unique test, ordering each unique test, and assessment requiring an independent historian. Category 2 is there would need to be an independent interpretation of a test performed by another physician or other qualified health care professional, not separately reported. In terms of risk of complications, there should be a moderate risk of morbidity from additional diagnostic tests or treatment. Some examples include prescription drug management, decision regarding minor surgery with identified patient or procedure risk factors, and decision regarding elective major surgery without identified patient or procedure risk factors. There are additional examples listed here. The final code for new patient office visits is code 99205, the highest level code for new patient office visits, which requires a high level of medical decision making. If using time for code selection, this code would require 60 to 74 minutes total time spent on the date of the encounter. If the visit goes beyond 74 minutes, you may be able to add a prolonged services code in addition to billing 99205. This is the table outlining requirements for high level medical decision making. For number and complexity of problems addressed to be considered high, you would need to report one of the following. One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment, or one acute or chronic illness or injury that poses a threat to life or bodily function. Data reviewed needs to be extensive, therefore you would need to meet the requirement of at least two out of three of the categories listed. Category 1 requires any combination of three of the following items. Review of prior external notes from each unique source, review of results of each unique test, ordering of each unique test, and assessment requiring an independent historian. Category 2 is independent interpretation of a test performed by another physician or other qualified health care professional, not separately reported. And Category 3 is discussion of management or test interpretation of external physician or other qualified health care professional or other appropriate source, not separately reported. There also has to be a high risk of morbidity from additional diagnostic testing or treatment. Examples include drug therapy requiring intensive monitoring for toxicity and decision regarding elective major surgery with identified patient or procedure risk factors. As you can see, there are several additional examples included in this table. Established patient E&M codes in the code range 99211 through 99215 include descriptors that outline the key components necessary to use each code. For an established patient, all of the key components in the physician's documentation must meet or exceed the requirements of the code descriptor in order to qualify for the level of service. Code 99211 is a very simple code. It is required that someone be present for the evaluation but does not require the presence of a physician or other qualified health care professional. There are no significant complexities or risks of complication or morbidity for code 99211, so the MDM table elements and total time do not apply here. Code 99212 requires straightforward medical decision making and if you are using total time to determine the level of service, 10-19 minutes must be spent on the date of the encounter. Again, the medical decision making should be considered straightforward and the number and complexity of problems addressed should be minimal, as noted here. One self-limited or minor problem. The amount and complexity of data to be reviewed should be minimal or none. And the risk of complications and or morbidity or mortality of patient management should be minimal risk of morbidity from additional diagnostic testing or treatment. Now let's move on to code 99213, where the keyword now regarding level of service is low. If you are using total time to determine the level of service, 20-29 minutes of total time is spent on the date of the encounter. When reviewing the MDM table of elements for code 99213, there is a low level of medical decision making. The number and complexity of problems addressed are considered low if one of the following is documented. Two or more self-limited or minor problems or one stable chronic illness or one acute uncomplicated illness or injury. When looking at the data, it should be limited and you must meet the requirements of at least one of the two categories. For Category 1, there can be any combination of two of the following. Review of prior external notes from each unique source. Review of the results of each test and ordering of each test. Category 2 requires an assessment requiring an independent historian. There should also be a low risk of morbidity from additional diagnostic testing or treatment. Next up is code 99214. This code requires a moderate level of medical decision making. If using total time to select the level of service, 30-39 minutes is required on the date of the encounter. You will notice, just as it was in the MDM tables for the new patient E&M codes, each level gets more and more complex. Again, medical decision making for code 99214 should be moderate. So let's start by reviewing the number and complexity of problems addressed, which should include one or more chronic illnesses with exacerbation, progression, or side effects of treatment, or two or more stable chronic illnesses, or one undiagnosed new problem with uncertain prognosis, or one acute illness with systemic symptoms, or finally, one acute complicated injury. Data review requires that you meet one out of the three categories. For Category 1, you can have any combination of three of the following, review of prior external notes from each unique source, review of results of each unique test, ordering of each unique test, and assessment requiring an independent historian. Category 2 includes independent interpretation of a test performed by another physician or other qualified health care professional, not separately reported. Category 3 includes discussion of management or test interpretation of external physician or other qualified health care professional or appropriate source, not separately reported. There is also a moderate risk of morbidity from additional diagnostic testing or treatment for code 99214. Examples include prescription drug management and decision regarding minor surgery with identified patient or procedure risk factors. Again, there are more examples listed here. Finally, code 99215 is the highest level of service that can be provided for an office visit and requires a high level of medical decision making, or 40 to 54 minutes on the date of the encounter when using total time. Again, if this visit requires 55 minutes or longer, you may be able to report a prolonged service code in addition to code 99215, as is with 99205. Code 99215, again, requires a high level of medical decision making and a high number of complexity and problems addressed, including one or more chronic illnesses with severe exacerbation, progression, or side effects of treatment, or one acute or chronic illness or injury that poses a threat to life or bodily function. The data review for 99215 must be extensive and must meet requirements of at least two out of three categories. Category 1 includes any combination of three of the following. Review of prior external notes from each unique source. Review of results of each unique test. Ordering of each unique test. And assessments requiring an independent historian. Category 2 includes independent interpretation of a test performed by another physician or other qualified healthcare professional, not separately reported. Category 3 includes discussion of management or test interpretation of external physician or other qualified healthcare professional or appropriate source, not separately reported. For risk of complications, there must be a high risk of morbidity from additional diagnostic testing or treatment. Examples include drug therapy requiring intensive monitoring for toxicity and decision regarding elective major surgery with identified patient or procedure risk factors. Additional examples are listed in the table here. These tables can be found in the AASM coding and reimbursement E&M resources on the AASM website. Since there was so much time dedicated to explaining the MDM table of elements for each code, here is a summary of the total times associated with each level of complexity and E&M code. Notice that the new patient time ranges differ from the established patient time ranges. One last time, we will reiterate that the total time refers to all time spent on the date of the encounter. It is important to note that you can choose to select a time-based code regardless of whether the majority of the visit was spent on counseling. Also, both face-to-face and non-face-to-face activities can contribute to the total time. Remember that E&M services are assigned based on whether the patient is new or established and based on the level of service provided. Also keep in mind, the level of service is determined based on medical decision-making or total time. Medical decision-making focuses on the number of diagnoses and management, amount or complexity of data reviewed, risk of complications, and also associated comorbidities. The most important thing to do is to accurately document all appropriate information to support the level of service and code selection. General documentation principles should be followed. The medical record should be complete and legible. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred. Past and present diagnoses should be accessible to the treating and or consulting physician. Appropriate health risk factors should be identified. The patient's progress, response to changes in treatment, and revision of the diagnosis should be documented. The CPT and ICD-10-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record. Learning to appropriately assign evaluation and management codes is one of the more difficult challenges of coding and billing. It is important to review the guidelines at the beginning of the E&M section of the CPT codebook for instructions and guidance. You are now ready to move on to Module 5 which will address public insurers and insurer policies.

AASM Coding Education Program

evaluation and management coding

office or outpatient setting

E&M codes

2021 guidelines

sleep centers