Here's Help to Master Use of Evaluation/Management Codes

The following information has been developed by APA's Committee on RBRVS, Codes, and Reimbursements and the staff of the Office of Healthcare Systems and Financing to provide APA members with practical information on the use of, selection of, and documentation for evaluation and management (E/M) codes.

General Information

E/M codes, codes in the 99XXX series, are used to denote a family of general medical services provided in various settings. While psychiatrists frequently use E/M codes for hospital inpatient services, inpatient and outpatient consultations, and nursing facility services, they use them less frequently for office and other outpatient services, emergency department services, and domiciliary, rest-home services.

Unlike most of the codes in the psychiatry section of the AMA's CPT manual, which are defined by time and place of service, E/M CPT codes are categorized by the following elements:

To use these codes appropriately, you should read the Evaluation and Management Services Guidelines section of the CPT manual. This section explains how to choose the appropriate level of service when using E/M codes and identifies the typical time a physician spends with the patient and/or family.

When Counseling and Coordination of Care Dominate the Session

When counseling and coordination of care account for more than 50 percent of the time spent with the patient, time becomes the sole element in determining the appropriate code. The clinician makes the selection by matching the time of the encounter (face-to-face or unit/floor) to the typical time listed for the appropriate E/M service. In this instance, there is no consideration of the extent of the history, exam, medical decision making required, or nature of the presenting problem.

For inpatient care, time is defined as unit/floor time and includes all work the clinician performs on behalf of the patient while present on the unit or at the bedside. In the outpatient, nonfacility setting, time includes only face-to-face time with the patient.

Defining Counseling and Coordination

Counseling is defined as a discussion with the patient and/or caregiver concerning one or more of the following: diagnostic results, prognosis, risks and benefits of treatment, instructions for management, compliance issues, risk-factor reduction, and patient and family education. Coordination is defined as discussions about the patient's care with other providers or agencies. Counseling should not be confused with psychotherapy. Psychotherapy is defined in the CPT manual as “Treatment for mental illness and behavioral disturbances in which the clinician establishes a professional contract with the patient and, through definitive therapeutic communication, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, and encourage personality growth and development.”

Documentation Vital

Documentation for all procedure codes has multiple elements, including history, diagnosis, decision making, safety assessment, and coding. The specifics vary within each code family. For the 908XX codes, the documentation is largely unspecified and at the discretion of the payer.

Documentation for E/M codes is driven by the nature of the visit. If counseling and coordination of care dominate, then the total length of time (face-to-face/unit-floor) and a record of the counseling and coordination activities provided should be documented. For all other services you are seeking to bill under E/M service codes, you should consult the 1997 Documentation Guidelines for Evaluation and Management Services published by CMS and posted at<www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp>. Following these documentation guidelines will satisfy the Medicare program's documentation requirements and should be acceptable to private insurers as well.

The staff of the APA Office of Healthcare Systems and Financing is available to address specific questions at (800) 343-4671 or [email protected].▪