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E/M Coding
See AAOS Now (Davidson, J)
Key Components
- History
- Exam
- Medical decision-making
History
Chief Complaint
- concise statement describing the reason for the encounter. Usually stated in the patient's words.
History of Present Illness (HPI)
- Chronological description of the development of the patient's present illness
- Location - shoulder pain
- Severity - pain is 5 on a scale of 10
- Timing - every night, constant pain, pain comes and goes)
- Modifying factors - activity which exacerbate or alleviate symptoms: exacerbated with overhead activity, alleviated with rest.
- Quality - dull, aching, throbbing, stabbing
- Duration - 2 days, 2 months, 2 years etc
- Context - Circumstances causing the symptoms
- Associated signs and symptoms -
Review of Systems (ROS)
- May be obtained through use of a patient completed questionnaire
- Constitutional (weight loss, fever, fatigue, appearance)
- ENT
- Eyes
- Cardiovascular
- Respiratory
- GI
- Genitourinary
- Skin
- Musculoskeletal
- Neurologic
- Psychiatric
- Hematologic & Lymphatic
- Endocrine
- Allergy & Immunology
- "Patient completed ROS questionnaire was reviewed and is signed and dated in the chart. Pertinent postivies include:"
Past Medical History, Family Medical History, Social History (PFSH)
- PMH
- PSH
- Medications
- Family History non-contributory
* The family history describes parents, siblings, children, genetic diseases of the family, etc. If the family history is not a contributing factor to the patient's illness, remember to document this as "non-contributory."
- SH: smoking, alcohol, marital status, employment, etc).
- "Past Medical History, Family Medical History, and Social History patient questionnaire was reviewed and is signed and dated in the chart. Pertinent postivies include:"
Exam
Body areas recognized
* Head, including face
* Neck
* Chest, including breasts and axillae
* Abdomen
* Genitalia, groin, buttocks
* Back, including spine
* Each extremity
Organ systems recognized
* Constitutional (height, weight, blood pressure, physical appearance) [1995 guidelines]
* Eyes
* Ears, nose, mouth, and throat
* Cardiovascular
* Respiratory
* Gastrointestinal
* Genitourinary
* Musculoskeletal
* Skin
* Neurologic
* Psychiatric
* Hematologic/Lymphatic/Immunologic
Coding based on time
- Duration of the visit may be utilized to determine the level of the service if >50 percent of the face-to-face time is spent providing counseling or coordination of care.
- Face-to-face time: includes time spent obtaining a history, performing an examination, and counseling/coordination of care.
- Floor/unit time: includes time establishing and/or reviewing the patient chart, examining the patient, writing notes, and communicating with the patient's family and/or other healthcare professionals.
- When time is considered the "key" or controlling factor, the time that a resident/fellow spends with a patient does not count
- Must document:
* Total time of encounter
* Total time spent counseling
* Description of your counseling
New patient is defined as a patient who has not been seen by you within the past three years and has not been seen by another provider in your specialty group.
Established patient has been seen by you within the past three years or was seen by another provider in your specialty group.
Consults: request for a consultation from an appropriate source and the need for consultation must be documented in the patient's medical record. Consultant must provide written report of his/her findings to the referring physician.
Post-Operative Exam codes (within 90 day global period)
- EM code = 99499
- V58.78 (aftercare following surgery of musculoskeletal system)
- V54.81 (aftercare following joint replacement)
- V54.89 (aftercare for healing fracture)
- V54.19 (aftercare for healing traumatic fracture)
Post-Operative Exam Codes (after 90 day global period)
- Use standard EM code
- V67.00 (postsurgical exam)
- V67.9 (follow-up exam)
- V67.4 (exam following treatment of fracture)
Common modifiers:
* -24 applies to an unrelated E&M service provided during the postoperative (or global) period by a single physician.
* -79 applies to an unrelated procedure performed during the global period, rather than an unrelated E&M service.
* -25 applies when a significant, separately identifiable E&M service is performed by a single physician on the same day of another procedure or other service. This must be clearly documented in your note.
* -51 applies when multiple procedures or surgeries are performed during a single visit.
* -50 represents bilateral procedures were performed.
* -53 represents a discontinued procedure.
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