Here are some tips for selecting evaluation and management CPT® codes for patient encounters:
- Familiarize yourself with the evaluation and management code changes. The E/M guidelines have specific updates to each practice setting. So it is important to review the guidelines for hospital vs. ER vs. nursing homes vs. outpatient clinic visits before selecting a code. The guidelines provide information on the documentation requirements, key components for code selection, and time-based criteria.
- Review the medical record thoroughly. To select the appropriate evaluation and management code, you need to have a complete understanding of the patient’s medical history and current condition. Be sure to review all relevant medical records, including the history and physical examination, progress notes, diagnostic test results, and treatment plans. Reviewing this medical information can be used to help choose the correct evaluation and management code.
- Choose a method for coding. The 2021 and 2023 evaluation and management code changes now allow healthcare providers to code by time or medical decision making. Determine which method you will use to code the patient encounter. The chosen method may differ from the next patient. It is important to know how to code by both time and medical decision making so the highest yet accurate evaluation and management code can be chosen. This article will further discuss the updates of evaluation and management code changes.
- Code to the highest level supported by the documentation. When selecting an evaluation and management code, always code to the highest level supported by the documentation. If the documentation does not support a higher level of service, then code to the level that is supported. We are not looking to create fraudulent claims but rather chose the correct evaluation and management code.
- Choose the accurate evaluation and management code. Remember that accurate and appropriate E/M coding is crucial for ensuring that providers are reimbursed fairly for their services. If you have any doubts about selecting the appropriate code, consult with a coding specialist or your billing department. If you would like to learn more about choosing the correct evaluation and management code, check out The Basics of Billing and Coding Course.