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3M™ - E/M Coding with HCPCS/CPTFINDER In this activity, you will assign E/M codes for physician visit encounters using the HCPCS/CPTFINDER in the 3M Coding and Reimbursement System (CRS). Evaluation and management (E/M) codes are used to report and bill for services rendered to patients in the physician provider setting. Two levels of determination and guidelines, as well as various interpretations from various third-party payers, make the assignment of E/M codes very challenging for the HIM professional. Using a software application to characterize, report and bill these E/M codes, although not controversial, still presents difficulties for accurate assignment. We expect software applications to assist us with accuracy and consistency. However, the assignment of E/M levels requires subjective analyses of level of risk as well as whether documentation provided by the physician indicates medical necessity for services rendered. Encoders, which include a computer-assisted coding element, will suggest possible codes to use for a visit associated with the diagnoses and documentation that the provider has used in the notes. These types of systems help the coding professional to work more efficiently and productively. While most encoder applications provide the technological path to assign E/M code levels, it still takes a great deal of knowledge concerning the definitions and rules to achieve the correct result. Some coding professionals prefer using an encoder alone, while others prefer the books and still others utilize both to achieve the most accurate E/M code for the encounter. Important! You will need to access the following four physician encounter notes as part of this activity, and may need to reference them to answer associated assessment questions:  Office Visit 1  Office Visit 2  Office Visit 3  Office Visit 4 The 2021 E/M Services Guidelines for office and other outpatient services have radically changed from the E/M principles of prior years. Specifically, the E/M guidelines for these services in 2021 and beyond have been revised to reduce the subjectivity often inherent in the prior 1995 and 1997 guidelines. The new guidelines also support the Patient over Paper initiatives of CMS. January 1, 2023 saw another sweeping revision of E/M coding structures. Other categories of E/M have not changed from prior years. It is important to understand that these guidelines do not establish the documentation requirements for visits, nor do they dictate standards of care. They are established to measure what has been included in the provider documentation; either by time or medical decision making. While in this activity you will utilize the encoder as a tool for the assignment of E/M codes, you still need to know how to properly use that tool. There are many “paths” to take when utilizing an encoder for this

purpose, and coding professionals must utilize their knowledge of coding definitions, rules, and guidelines to arrive at the correct assignment. You will find it helpful to have your CPT ® code book alongside you as you complete this activity, as well as the following document provided by the American Medical Association (AMA):  AMA’s CPT Evaluation and Management (E/M) Office or Other Outpatient (99202-99215) and Prolonged Services (99354, 99355, 99356, 99417) Code and Guidelines Changes  AMA’s CPT ® Evaluation and Management (E/M) Code and Guideline Changes Optional Resources This activity – and assigning E/M code levels with the encoder in general – requires knowledge of coding guidelines and definitions from CPT. The AMA’s Ed Hub offers free educational material covering the 2021 CPT E/M changes. (Note that you will need to create a free account to view the learning modules.) The following two resources will be especially helpful:  Revisions to the CPT E/M Office Visits: New Ways to Report Using Time  Revisions to the CPT E/M Office Visits: New Ways to Report Using Medical Decision Making (MDM) The “ Evaluation and Management Services ” publication provided by Centers for Medicare & Medicaid Services (CMS) is an excellent resource regarding the assignment of E/M codes and their associated definitions. This site has not been updated at time of this AHIMA VLab ® activity’s last publication, but it is beneficial to bookmark the CMS link for review later. 3M is a trademark of the 3M company. CPT Copyright 2022 American Medical Association. All rights reserved. CPT ® is a registered trademark of the American Medical Association. Part 1 The directions below will lead you through Part 1 of the “E/M Coding with HCPCS/CPTFINDER” activity and will be used to answer assessment questions 1-5. ASSIGN E/M CODE TO CASE 1 Step 1: Navigate the E/M assignment pathway using the HCPCS/CPTFINDER.  Review the document entitled “ Office Visit 1 ,” for patient Linda Dunhouse.  In the 3M CRS set the gender of this patient as Female .  Enter 57 for Age at Admission.  Enter 7/10/2022 or use the calendar icon for the Admit Date.  Enter 7/10/2022 or use the calendar icon for the Discharge Date.  Note the automatic calculation of the Length of Stay.

 Enter Linda Dunhouse in the Patient Identification field.  Using the drop-down arrow, select HCPCS/CPTFINDER in the Product field.  Note that the Admit Date field is now grayed out as unavailable, as outpatient stays calculate only on a service date (not admit and discharge dates).  Select Continue . Step 2: Add an E/M Procedure to the encounter.  Select Add Procedure from the ICD-10 Summary screen.  Enter E/M in the Enter Keyword or Code search box.  The screen may advance automatically to the E/M selection options, or you may have to select Continue .  Select option 1. E/M (EVALUTION AND MANAGEMENT) from the CPT Procedure screen.

 From the EVALUATION AND MANAGEMENT menu prompts, select option 4. OTHER EVALUATION and MANAGEMENT SERVICES.  From the EVALUATION AND MANAGEMENT SERVICES (E/M) screen options, select B. OUTPATIENT OFFICE/HOSPITAL .

 From the OFFICE/HOSPITAL OUTPATIENT menu options, select option 6. OTHER/UNSPECIFIED .  From the OFFICE/OUTPATIENT E/M Services menu options, select option 2. NEW PATIENT .

 Select the question mark icon to the left of option 1, medical decision making (MDM), to review the Nosology Help Message for the coding guidelines referring to MDM.  When finished, select OK to close this Help Message.  Now select 1. MEDICAL DECISION MAKING from the SELECTION OF E/M LEVEL BASED ON menu. IDENTIFY NUMBER AND COMPLEXITY OF PROBLEMS ADDRESSED AT THE ENCOUNTER TO MEET THE CHARACTERISTICS OF E/M CODE LEVELS Step 1: Evaluate the Assessment/Plan in the encounter note for Linda Dunhouse.  Review Linda Dunhouse’s encounter note.  In your CPT or other MDM table reference document, review the definitions and guidelines for establishing the Level of MDM as straightforward (99202), low (99203), Moderate (99204) or High (99205).  Linda’s number and complexity of problems addressed at the encounter includes hepatomegaly, hypertension and emphysema.

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