How do healthcare providers accurately assign Evaluation and Management (E&M) codes for patient visits?

How to Accurately Assign E&M Codes for Patient Visits

Healthcare providers should assign E&M codes based on either total time spent on the encounter (including same-day non-face-to-face work) or medical decision-making complexity, whichever results in the higher level of service, while ensuring documentation accurately reflects the clinical work performed rather than simply meeting billing requirements. 1, 2

Current E&M Coding Framework (2021 Forward)

The fundamental approach to E&M coding changed dramatically on January 1,2021, simplifying the previous complex system:

• Time and medical decision-making (MDM) are now the sole determinants of the E/M level for outpatient visits (codes 99202-99215), eliminating the previous requirements for detailed history and physical examination documentation 3, 2
• When using time as the determining factor, document total time spent on the encounter, including non-face-to-face work performed on the same day of the visit 1
• When using MDM, focus on the complexity of problems addressed, amount and complexity of data reviewed, and risk of complications or morbidity 2

Specific Code Selection by Visit Type

New Patient Visits (99201-99205)

• Use code 99204 for evaluations that are detailed and moderately complex OR take at least 45 minutes (with more than half spent counseling) 4
• Use code 99205 for evaluations that are comprehensive and highly complex OR take 60 minutes (with more than half spent counseling) 4

Established Patient Visits (99211-99215)

• Use code 99214 for evaluations that are detailed and moderately complex OR take at least 25 minutes (with more than half spent counseling) 4, 1
• Use code 99215 for evaluations that are comprehensive and highly complex OR take 40 minutes (with more than half spent counseling) 4

Observation Unit Encounters

• Use outpatient E/M codes (99201-99215 or 99241-99245) for ER observation units, NOT inpatient codes (99221-99223), as observation services are considered outpatient regardless of physical location 5

Documentation Best Practices

What to Document

• Document the type of encounter (new problem versus chronic problem review) to demonstrate expertise and decision-making complexity 1
• Focus documentation on clinical decision-making and care management activities rather than irrelevant historical elements or boilerplate findings 4
• Document the patient's story in sufficient detail to accurately retell it, supporting patient care and clinical outcomes rather than simply meeting billing requirements 1

Appropriate Use of EHR Tools

• One-click templates and macros for normal physical examination findings are acceptable as long as the final signed documentation accurately reflects what occurred during the encounter 6
• Indicate the source of pulled data and supplement with appropriate narrative content when using EHR tools 1
• Avoid "cloned" documentation where each entry is worded exactly like previous entries, as this is considered misrepresentation by CMS 6

Critical Pitfalls to Avoid

Common Coding Errors

• Nearly 40% of E&M claims are miscoded: 26% are upcoded and 14.5% are downcoded, representing significant compliance risks 1
• Prior to provider education, 60% of encounters were inaccurately billed, representing a potential 35% loss in work relative value units 7
• No significant difference exists in coding errors between paper records and EHRs, despite EHRs being designed to help with "right coding" 4, 1

Compliance Risks

• Improper E&M coding can lead to accusations of billing fraud with potential fines, exclusion from Medicare/Medicaid programs, and criminal penalties 1
• Document all telephone encounters for which a patient is charged, including date, time, patient information, reason for call, total encounter time, relevant history, assessment, plan, and disposition 1

Improving Coding Accuracy

Provider Education Strategies

• Dynamic billing feedback systems significantly improve coding accuracy: In one study, accuracy increased from 40% to 70% after one year of targeted feedback, reducing potential wRVU loss from 35% to 10% 7
• Provider education and feedback systems, combined with well-defined organizational standards, can markedly improve coding accuracy 1, 8
• Team-based coding interventions ensure documentation accurately reflects the complexity of care delivered, with one institution increasing revenue by $233,989 per 10,000 encounters through improved accuracy 8

Prolonged Services Add-On Codes

• When visits require considerably more time than typical, use prolonged service codes (99354 for first 30-74 minutes face-to-face, 99355 for each additional 30 minutes) in addition to the base E/M code 4
• Non-face-to-face prolonged service codes (99358,99359) are also available for same-day work 4