What Is E/M Coding?
Evaluation and Management (E/M) codes represent office visits, hospital visits, and consultations where a provider evaluates and manages a patient's condition. E/M coding is among the most frequently used and audited code sets in outpatient and inpatient billing.
E/M Levels
E/M codes are stratified by visit complexity, typically ranging from level 1 (straightforward) to level 5 (highly complex), with separate code sets for new versus established patients and different settings such as office, hospital, or emergency department.
Medical Decision Making (MDM) Complexity
Under the 2021 guideline changes, code level selection for office and outpatient E/M services is based on either medical decision making or total time. MDM complexity is determined by three elements: the number and complexity of problems addressed, the amount and complexity of data reviewed, and the risk of complications or morbidity from patient management.
Time-Based Coding
Providers may alternatively select an E/M level based on total time spent on the date of the encounter, including both face-to-face and non-face-to-face activities like reviewing records and documenting the visit, as long as that total time meets the threshold for the chosen code.
2021 Guideline Changes
The 2021 changes eliminated the previous history and physical exam components as level-determining factors for office visits, instead focusing coders and providers on MDM or time, significantly simplifying documentation requirements.
Split/Shared Visits
Split or shared visits occur when a physician and a non-physician practitioner, such as a nurse practitioner, both provide face-to-face portions of an E/M service on the same date. Billing rules determine which provider's National Provider Identifier is used based on who performed the substantive portion of the visit.
Exam Tip
Know that history and exam are no longer level-determining factors for office E/M visits under the 2021 guidelines.