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Rational Physician
Coding
 

 

 


Effective January 1, 2023, this information is no longer up-to-date. The material on this page covers only the 1995 and 1997 E/M guidelines and is no longer accurate. A new set of E/M guidelines was released in 2021, with some minor modifcations added for 2023. These new guidelines are now used to document all encounters in both the outpatient and inpatient settings. For the most recent E/M coding guidance, visit our home page here.

 

Introduction and Definitions

The purpose of this tutorial (and of this entire website) is to provide physicians with the tools they need to educate themselves about E/M coding and documentation.  The fundamental principle of E/M University is that knowledge is power when it comes to E/M coding and documentation.  Too many physicians are chronically undercoding for their services because they don’t understand the rules.  A working knowledge of the E/M coding is the best way to ensure optimal compliance and avoid inadvertent undercoding.   Physicians who are facile with the idiosyncratic process of E/M documentation can command a higher rate of return on their cognitive labor than their less E/M-savvy counterparts.  In other words if you know how to accurately bill for your services, there is a better chance you will get paid for what you really do.

E/M stands for “evaluation and management”.  E/M coding is the process by which physician-patient encounters are translated into five digit CPT codes to facilitate billing.  CPT stands for “current procedural terminology.” These are the numeric codes which are submitted to insurers for payment.  Every billable procedure has its own individual CPT code.  

The CPT codes which describe physician-patient encounters are often referred to as “E/M codes”   There are different E/M codes for different types of encounters such as office visits or hospital visits.  Within each type of encounter, there are different levels of care.  For example, the 99214 code may be used to charge for an office visit with an established patient.  There are five levels of care for this type of encounter.  The 99214 code is often called a “level 4” office visit because the code ends in a “4” and also because it is the fourth “level of care” for that type of visit (with the 99215 being the fifth and highest level of care).  Each patient care encounter may be viewed as a unique procedure which requires specific documentation. 

The Key Components of E/M Documentation

The documentation for E/M services is based on three “key” components:

  1. History
  2. Physical Exam
  3. Medical Decision-Making

We have developed a comprehensive series of web-based E/M coding courses (video tutorials) which provide physician-to-physician E/M coding education. All courses are designed and narrated by Peter R. Jensen, MD, CPC, a practicing physician and certified professional coder. Our approach to E/M coding education is unique because we focus on clinical issues first and then discuss E/M coding and documentation in a language physicians can actually understand.

 

 



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Click to return to E/M University Home page, EM Coding Education