A four-step process for quicker, easier evaluation and management coding

After several months of using the new evaluation and management (E/M) coding rules, it has become clear that the most difficult chore of coding office visits now is assessing data to determine the level of medical decision making (MDM).

Analyzing each note for data points can be time-consuming and sometimes confusing. Fortunately, the majority of visits can be optimally coded without worrying about data at all, if you follow these four steps:

1. Think time first. Under the new rules, physicians may code any visit based solely on the total time it took on the date of service (including the time spent preparing for the visit and the time spent documenting it afterwards). If your total time spent on a visit appropriately credits you for level 3, 4, or 5 work, then document that time, code the visit, and be done with it. But if it does not, go to Step 2.

2. “Problems plus.” The level of MDM is determined by the problems addressed at the visit, the data reviewed, and the patient’s risk. But many visits can be coded with MDM just by answering these two questions: What was the highest-level problem you addressed during the office visit? And did you order, stop, modify, or decide to continue a prescription medication? Prescription drug management combined with a level 3 or 4 problem equals a level 3 or 4 visit. If the patient has a level 5 problem, and you consider admission, that’s a level 5 visit. On the rare occasions when you see a patient for level 4 or 5 problems for less than the required time and don't do any prescription drug management, you may have to proceed to Steps 3 and 4.

3. Level 4 problem with social determinants of health or simple data. If you see a patient for a level 4 problem, but don’t do prescription drug management, you can still code it as a level 4 visit if you do any of the following:

• Personally interpret a study (e.g., an X-ray),
• Discuss management or a test with an external physician,
• Modify the workup or treatment due to social determinants of health.

4. Level 4 or 5 problem with complex data. If you saw a patient for a level 4 problem and still haven't been able to code the visit at this point, you have to tally Category 1 data points:

• Review/order of each unique test equals one point each,
• Review of external notes from each unique source equals one point each,
• Use of an independent historian equals one point.

Once you reach three points, code it as level 4.

For a level 5 problem, if you see a really sick patient, order/interpret an X-ray or ECG, and review/order two lab tests, then code level 5.

See the full FPM article: “A Step-by-Step Time-Saving Approach to Coding Office Visits.”