Evaluation and Management Coding Top to Bottom

Evaluation and Management coding is detailed. It requires steps that contain multiple smaller steps. It’s a lot like an onion—many layers and the potential to make you cry. Many of our students, perhaps even the majority, express frustration in learning the E&M process. Rubbing salt in the wound is the fact that E&M (Evaluation and Management) coding is absolutely an essential skill for coders, particularly outpatient coders.

In the CareerStep courses we teach E&M from the bottom up, presenting the small steps first and putting them together to build the code. This is as it should be because ultimately that is how the process is performed on the job. However, it is also helpful to have a different perspective, a top down look at how E&M codes are built and why they are as detailed as they are. Since physicians get paid when they report E&M codes, it can also be helpful to include money in this view. It always comes down to cash anyway, right?

When you go see the doctor he or she (we’ll make it a she for the rest of the topic) will do 3 basic things: (1) ask you what’s wrong, (2) try to see for herself what’s wrong, and (3) use her expertise as a physician to help you. These 3 things mirror the three key components of an E&M code:

1. Ask you what’s wrong – Extent of History Obtained
2. Try to see for herself what’s wrong – Extent of Examination Performed
3. Use her expertise as a physician to help you – Complexity of Medical Decision Making

How detailed your doctor gets on the first two and how difficult her job is on the third one determines how much she gets paid for your visit (at least for the E&M part). I know you are just dying to break that down further! Here we go:

History
Chief complaint? You likely give this to the front desk when you come in the office. This is the most basic piece of info—it’s the reason you’re at the clinic. HPI (History of Present Illnesses) has 8 different possibilities. These are things like when the symptoms started, how bad they are, what makes them worse or better, and what additional symptoms you are having. PFSH (Past, Family, Social History) is a quick review of the medical history of you and of your family as well as elements of your social habits. ROS (Review of Systems) round out the history with questions about symptoms you might be experiencing related to specific body systems. Take note that the majority of this info is gathered from Q&A (Question and Answer) you the patient reporting info to your doctor.

Exam
This part is all objective, observable info noted by your physician. To make these observations the doctor needs to see, hear, feel, or smell things and report them. As coders, we compartmentalize them into body systems, much like the ROS with the important distinction that exam elements are objective notes made from the physician’s inspection of the patient.

MDM (Medical Decision Making)
This level is assigned based on how complex the case is for your doctor. Factors in consideration are whether your problem is new or one she has treated you for previously, what type of medical info she has to review (labs, old records, x-rays), and how much risk of complications is involved. Risks are from how severe your illness is and whether you have other conditions that the physician needs to think about when planning your treatment as well as the nature of diagnostic and therapeutic procedures necessary to treat you.

In summary, whichever way you view E&M coding, it is a challenge and a process. It can be aggravating at first to realize that all these steps only produce one code. Just remember that E&M is essential to the physician getting paid, and in turn, to you getting paid. Like the other parts of the coding process, it will take plenty of good practice for E&M to become second nature, but through all that practice the onion of E&M is definitely NOT worth crying about.