Understanding Basics of Evaluation and Management Service

Understanding Basics of Evaluation and Management Service

Basics of Evaluation and Management Service

As the name Evaluation and Management (E/M) suggest, E/M codes apply to visits and services that involve evaluating and managing patient health. Evaluation and management (E/M) procedure (CPT) codes ranges from 99202 to 99499 representing services provided by a physician or other qualified healthcare professional. Standard example of E/M services include office visits, hospital visits, home services, and preventive medicine services. Services like surgeries and radiologic imaging are not considered as evaluation and management services. In this article, we will share basics of Evaluation and Management service including applicable procedure codes, level of E/M service, split/shared critical care, and coordination of care and/or counseling.

Selection of Level of Evaluation and Management Service

Coding team or physicians need to select the code for the service based upon the content of the service. The duration of the visit is an supplementary factor and does not control the level of the service to be billed unless more than 50 percent of the face-to-face time (for non-inpatient services) or more than 50 percent of the floor time (for inpatient services) is spent providing counseling or coordination of care. In case of Medicare, any physician or non-physician practitioner (NPP) authorized to bill Medicare services will be paid at the appropriate physician fee schedule amount based on the rendering national provider identifier (NPI) number. ‘Incident to’ Medicare Part B payment policy is applicable for office visits when the requirements for ‘incident to’ are met.

Split (or Shared) Critical Care Visits

A split (or shared) visit is an evaluation and management (E/M) visit in the facility setting that is performed in part by both a physician and a non-physician practitioner (NPP) who are in the same group, in accordance with applicable law and regulations such that the service could be could be billed by either the physician or NPP if furnished independently by only one of them. Payment is made to the practitioner who performs the substantive portion of the visit. CPT code 99291 can be billed for the initial service add-on CPT code 99292 for additional time.

When critical care services are furnished as a split (or shared) visit, the substantive portion is defined as more than half the cumulative total time in qualifying activities that are included in CPT codes 99291 and 99292. Since, unlike other types of E/M visits, critical care services can include additional activities that are bundled into the critical care visits code(s), there is a unique listing of qualifying activities for split (or shared) critical care. To bill split (or shared) critical care services, you can first reports CPT code 99291 and, if 75 or more cumulative total minutes are spent providing critical care, the billing practitioner reports one or more units of CPT code 99292.

Duration of Coordination of Care and/or Counseling

When counseling and/or coordination of care dominates (i.e., more than 50 percent) the face-to-face physician/patient encounter or the floor time (in the case of inpatient services), time is the key or controlling factor in selecting the level of service. In general, to bill an E/M code, the physician must complete at least 2 out of 3 criteria applicable to the type/level of service provided. However, the physician may document time spent with the patient in conjunction with the medical decision-making involved and a description of the coordination of care or counseling provided. Documentation must be in sufficient detail to support the claim.

For an example, a cancer patient has had all preliminary studies completed and a medical decision to implement chemotherapy. At an office visit the physician discusses the treatment options and subsequent lifestyle effects of treatment the patient may encounter or is experiencing. The physician need not complete a history and physical examination in order to select the level of service. The time spent in counseling/coordination of care and medical decision-making will determine the level of service billed.

In the office and other outpatient setting, counseling and/or coordination of care must be provided in the presence of the patient if the time spent providing those services is used to determine the level of service reported. It’s crucial to note that face-to-face time refers to the time with the physician only. Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. And hence, the time spent by the other staff is not considered in selecting the appropriate level of service. The code used depends upon the physician service provided.

While billing for inpatient setting, the counseling and/or coordination of care must be provided at the bedside or on the patient’s hospital floor or unit that is associated with an individual patient. Time spent counseling the patient or coordinating the patient’s care after the patient has left the office or the physician has left the patient’s floor or begun to care for another patient on the floor is not considered when selecting the level of service to be reported. The duration of counseling or coordination of care that is provided face-to-face or on the floor may be estimated but that estimate, along with the total duration of the visit, must be recorded when time is used for the selection of the level of a service that involves predominantly coordination of care or counseling.

Highest Levels of Evaluation and Management Codes

Physicians are advised to bill the highest levels of visit codes, where the services furnished must meet the definition of the code. To bill a Level 5 new patient visit, the history must meet CPT’s definition of a comprehensive history. The comprehensive history must include a review of all the systems and a complete past (medical and surgical) family and social history obtained at that visit. In the case of an established patient, it is acceptable for a physician to review the existing record and update it to reflect only changes in the patient’s medical, family, and social history from the last encounter, but the physician must review the entire history for it to be considered a comprehensive history. The comprehensive examination may be a complete single system exam such as cardiac, respiratory, psychiatric, or a complete multi-system examination.

Medical Necessity

Medical necessity of a service is the primary criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is reasonable. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record.

Non-Physician Practitioners

Commercial payers along with Medicare will pay for evaluation and management services for specific non-physician practitioners (i.e., nurse practitioner (NP), clinical nurse specialist (CNS) and certified nurse midwife (CNM)). A physician assistant (PA) may also provide a physician service, however, the physician collaboration and general supervision rules as well as all billing rules apply to all the above non-physician practitioners. The service provided must be medically necessary and the service must be within the scope of practice for a non-physician practitioner in the State in which he/she practices.

We referred ‘Medicare Claims Processing Manual Chapter 12’ to explain basics of evaluation and management service. As you know, evaluation and management service are high-volume services. Even small mistakes can cause major compliance and payment issues if the errors are repeated on a large number of claims. To ensure accurate reporting and reimbursement for these services, you need expert medical billing partner. Legion Healthcare Solutions is a leading medical billing company providing complete billing and coding services. We can assist you in accurate selection of E/M codes while billing to government and commercial insurance carriers. To know more about our billing and coding services, contact us at 727-475-1834 or email us at info@legionhealthcaresolutions.com

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