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Evaluation & Management Visits

This page contains guidance regarding documentation and payment under the Medicare Physician Fee Schedule for evaluation and management (E/M) visits.

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• / E/M Rules for Office Visits: What Level of Medical Decision-Making?

E/M Rules for Office Visits: What Level of Medical Decision-Making?

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Under the E/M rules that went into effect on Jan. 1, 2021, the complexity of medical decision-making (MDM) is used to determine what level of E/M code you can use for an office visit. Make sure that your documentation validates the MDM level that you bill.

Four levels of medical decision-making. The overall complexity level of MDM can be straightforward or of low, moderate, or high complexity. To determine this overall level of MDM, you first look at three components (see next paragraphs) and determine which level of MDM complexity each of them would support (see “ E/M Resources ”). If at least two components indicate the same level of MDM, then that would determine the overall level of MDM. If the three components point to three different levels of MDM, then the mid­dle one would determine the overall level of MDM.

Component 1: The number and/or complexity of problems addressed at the patient encounter.

Component 2: The amount and/or complexity of data to be reviewed and analyzed.

Component 3: The risk of complica­tions and/or morbidity or mortality of patient management.

Which E/M codes can you bill for the office visit? The E/M codes that you can use depend on the complexity level of MDM:

• Straightforward: Use codes 99202 or 99212 for new and established patients, respectively.
• Low complexity: 99203 or 99213.
• Moderate complexity: 99204 or 99214.
• High complexity: 99205 or 99215.

Tackle These Three Cases

Based on the documentation for each of the exams below, determine which E/M codes to bill.

Case A: An infant with dacryosteno­sis. A pediatrician referred a patient to a pediatric ophthalmologist.

Impression. Intermittent, bilateral, congenital nasolacrimal duct obstruc­tion of a 9-month-old.

Plan. Lacrimal massage, twice a day. Antibiotic drops three times a day for three days to improve mucopurulent discharge. Discussed possible need for surgery, but not yet since there are some “clear” days with no symptoms.

Case B: A toddler’s swollen eyelid. A 3-year-old presented with a red, swollen left upper lid (LUL), with increasing severity over the previous two days. He had an associated upper respiratory infection.

Impression: Preseptal cellulitis LUL.

Plan: Considered ordering comput­ed tomography or magnetic resonance imaging of the orbit, but deferred that order since able to see full ocular motility. Discussion with pediatrician about Rocephin (ceftriaxone sodium) injection. Prescribed oral antibiotics for 10 days. Instructed patient’s mother to call if increased fever or swelling over the subsequent 24 hours.

Case C: A patient with shingles. A patient had shingles on the right side of her face and, ultimately, in her right eye. She had severe pain and photopho­bia in the right eye.

Impression: Zoster in the right eye.

Plan: Prescription drug management with acyclovir and topical steroids. Follow-up in one week or sooner. Phone conversation about findings and treatment with primary care physician.

Which E/M code would you bill for each of these exams? See answers below .

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Three common reasons for level 5 E/M office visits in primary care

Keith W. Millette, MD, FAAFP, RPH

If you’ve read the January/February issue of FPM , you know how to identify level 4 office visits under the new evaluation and management (E/M) guidelines and avoid losing money by under-coding them. But what about level 5 visits?

While not as common, level 5 visits do occur in primary care, and under-coding them can also have serious financial ramifications. To quickly identify and correctly code most level 5 office visits, keep in mind these three common reasons for level 5 work:

Reason No. 1: Time

The new guidelines allow coding of outpatient E/M office visits based solely on either total time on the date of service or medical decision making (MDM). Many level 5 office visits billed by family physicians will be based on time. If your total time is at least 40 minutes for an established patient or 60 minutes for a new patient, code that visit as a level 5.

Remember that total time includes all time spent caring for that patient on the day of the encounter. That means you count your prep time reviewing the chart before the visit, your face-to-face time during the visit, and the time you spend after the visit (as long as it occurs before midnight) reviewing studies, making phone calls, documenting your note, etc. (See these tips for tracking time .)

You must document your total time in the note. Because patients may read your notes, consider writing: “Total time was XX minutes. That includes chart review before the visit, the actual patient visit, and time spent on documentation after the visit.” This helps patients understand that you spend a lot of time behind the scenes caring for them, and it may even prevent confused patients from falsely accusing you of fraud (e.g., “He only spent 20 minutes with me, not the 40 minutes he listed in his note”) . Time spent on separately billed procedures done during an E/M visit does not count toward total time, so adding a statement such as “Time excludes procedure” is also helpful.

Reason No. 2: Pre-op visits for major surgery

To code a level 5 office visit using MDM you need at least two out of these three elements: high complexity problems, high risk, or extensive data review. Pre-op visits before elective major surgery in patients who have risk factors or require labs, X-rays, or electrocardiograms (ECGs) for evaluation/preoperative clearance often check these boxes.

There are two types of risk you can consider when it comes to pre-op visits: procedure risk and patient risk. Major surgery involves high procedure risk, including general anesthesia and the procedure itself (e.g., coronary artery bypass, total hip replacement, and abdominal surgery). Patient risk factors include morbid obesity, heart disease, diabetes, lung disease, etc. It is important to document both the patient risk factors and the procedure risk in your note.

The data portion of MDM is split into three categories:

1. Tests, documents, or independent historian(s); any combination of three from the following:

• Review of prior external note(s) from each unique source,
• Review of the result(s) of each unique test,
• Ordering of each unique test,
• Assessment requiring independent historian(s).

2. Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported).

3. Discussion of management or test interpretation with an external physician or other qualified health professional/appropriate source (not separately reported).

A visit must include at least two out of those three categories to qualify as level 5 “data” work. For level 5 pre-op visits, this commonly involves ordering/reviewing a minimum of three tests (e.g., labs , ECG, and chest X-ray) and interpreting at least one study (e.g., ECG or X-ray). To get credit for interpretation it must be clear in the note that you evaluated the study (e.g., “I personally evaluated the chest X-ray and it shows … ”) and did not just look at the report. Remember, if your health system is billing separately for the interpretation, you cannot count it toward your E/M visit level (for more tips on counting MDM data, click here ).

For practical purposes, the minimum criteria for coding level 5 pre-ops would look something like this as a simple equation: Level 5 pre-op = major surgery + risk factors + order/review three tests + interpret one study.

Reason No. 3: Very sick patients who require work up and/or admission decision

Very sick patients often require level 5 work if they have a high complexity problem such as acute respiratory distress, depression with suicidal ideation, or any new life-threatening illness or severe exacerbation of an existing chronic illness. It is common for these visits to qualify as high risk or require extensive data review, thereby pushing them into level 5 territory. Examples include the following:

1. Seeing a very sick patient (such as one with severe exacerbation or progression of their chronic condition, or side effects of treatment of their chronic condition) in the office who requires hospital admission (and you are not doing the admitting yourself) or requires you to contemplate admission (make sure to document your thought process in the note). This combines a high-complexity problem (or problems) with high risk.

2. Seeing a very sick patient (such as one with an acute or chronic condition that poses a threat to life or bodily function) who requires an office work up that qualifies as level 5 data review (e.g., ordering/reviewing a minimum of three tests and interpreting one study). This combines a high complexity problem (or problems) with extensive data.

To summarize, here are the three common reasons to code a level 5 office visit:

These are only a few useful examples of level 5 work. Less common scenarios may also qualify, such as visits that include decisions to de-escalate care or initiate do-not-resuscitate orders, decisions about emergency major surgery, and decisions about the use of drugs that require intensive monitoring. Referring to a coding template can be helpful for those scenarios. But for the three types of visits outlined above, you should not be afraid to think level 5 if your documentation supports it.

— Keith W. Millette, MD, FAAFP, RPH, is a family physician in Grand Forks, N.D.

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Is This Really Medically Necessary‪?‬ CodeCast | Medical Billing and Coding Insights

TPE audits from Medicare, along with private and commercial payer audits are on the rise. It is more important than ever to monitor physician records and make sure that when they submit any level of E/M. (Especially level 4’s and level 5’s.) In this episode, Terry reinforces making sure the visit not only meets the level of service billed, but also that the visit is even medically necessary to be able to be billed. Subscribe and Listen You can subscribe to our podcasts via: * Apple Podcasts – https://podcasts.apple.com/us/podcast/codecast-medical-billing-coding-insights/id1305926627 * Spotify – https://open.spotify.com/show/1lA69Q7EnjSMuVr3sXVWlX * TuneIn – https://tunein.com/radio/CodeCast–Medical-Billing-p1056702/ * YouTube – https://www.youtube.com/channel/UCoNm5vs6PFMIEDa5Undidlg * YouTube Music – https://www.youtube.com/playlist?list=PLQ8tk23yZroZslhtTVe-PEIjQsAoJZJIQ * Pandora – https://www.pandora.com/podcast/codecast-medical-billing-and-coding-insights/PC:1000156874 * Amazon Podcasts – https://music.amazon.com/podcasts/c9d8dc99-fced-45a2-82b4-0efdf144c897/CodeCast-Medical-Billing-and-Coding-Insights * iHeart Radio – https://www.iheart.com/podcast/256-codecast-medical-billing-a-31135434/ If you’d like to become a sponsor of the CodeCast podcast please contact us directly for pricing: https://www.terryfletcher.net/contact/

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