Coding Bootcamp: Introduction to Outpatient E&M

Welcome to one of a series of posts that I’m calling “Coding Bootcamp.”

The first topic? Outpatient evaluation and management (E&M) coding and billing.

Now, what exactly is E&M? Essentially, E&M services comprise everything we do in the outpatient setting and want to be reimbursed for doing. The most common of these services is, of course, outpatient clinic visits.

In this post, we’re going to walk through exactly what every note needs for optimal reimbursement.

What Every Note Needs

Gone are the days of counting dozens of discrete elements to justify an E&M level (i.e., a specific code, low/moderate/high).

However, each encounter still requires a “medically appropriate history and physical examination.” Now, though, the nature and extent of each is determined by the performing provider. In other words, no more counting individual components (whew). Likewise, for review of symptoms, only those pertinent to the chief complaint need be documented. Just make sure to document something.

The Different Kinds of Codes

Outpatient services range from 99202 - 99205 (new patient) and 99212 - 99215 (established patients). These are the CPT codes that medical billers will assign to each note based on how much is documented and how well. Document a lot, for instance, during a complex patient visit with multiple chronic illnesses? That might be assigned a 99204 (moderate). Document a little, during a visit for the sniffles? That might be assigned a 99203 (low), or even 99202 (straightforward).

Also, not while there is a “straightforward” service (99202, 99212), the threshold for a “low” service is so, well, low, that a straightforward service should almost never be used.

Time-based Billing

You can bill based on medical decision making or time, and I think an efficient outpatient practice will mix and match between the two.

Time-based billing is fairly intuitive. Spend the minimum amount of minutes in an encounter (including both pre- and post-clinic work, so long as it is on the day of encounter) and you meet criteria. Eligible activities include reviewing tests, the actual face-to-face time during a visit, ordering medications/tests/procedures, communicating with other healthcare professionals, documenting clinical information, interpreting tests, and care coordination. Note that these activities include both face-to-face and non-face-to-face time.

Medical Decision Making-based Billing

Medical decision making, or MDM, is a bit more complex.

MDM comprises three separate components: number and complexity of problems addressed, amount of data reviewed, and risk of morbidity and/or mortality from additional testing or treatment. The overall level billed is the average of all three components.

Number and complexity of problems addressed

This includes both new and established conditions that are addressed during the encounter.

Individual symptoms are not considered unique conditions, in so far as they refer to the same principal diagnosis (so, don’t count “GERD” and “heartburn” as two unique problems).

Likewise, co-morbidities are not considered unique conditions unless they are addressed during the encounter. To be considered a unique problem, it must be evaluated or treated as part of the visit. In other words, noting that a Cardiologist is managing the patient’s high cholesterol does not allow one to count high cholesterol as a second, chronic problem for purposes of MDM.

Amount of data reviewed

This includes most, if not all, of the data reviewed as part of the encounter, including medical records, labs, and imaging.

Note that ordering a test is also included as part of the visit in which it is ordered, and not the subsequent visit, because the assumption is that the ordering provider will review it, in due time.

So if you order a CBC, CMP, and coagulation profile - BOOM, that’s 3 tests reviewed as part of this visit.

Risk of morbidity and/or mortality

Essentially, this refers to the risk of complications from ongoing treatment.

Ultimately, and importantly, the risk is determined by the provider at hand. Some examples are commonly provided, but in the end it falls on the provider’s judgement.

Examples of moderate level risks include:

• Prescription drug management
• Minor surgery with risk factors
• Elective major surgery
• Healthcare limited by social determinants of health

And examples of high level risks include:

• Intensive drug management (rule of thumb, requiring labs every 3 months)
• Major surgery with risk factors
• Emergency surgery
• Decision to make someone DNR/DNI
• Decision to hospitalize or escalate level of care (e.g., to ICU)
• Parental controlled substances management

Ultimately, if you think a patient is at high risk for complications? Document it! That’s all that’s needed.