Optimize Reimbursement with Appropriate Level of Service Code

Determining the level of an evaluation and management (E/M) visit and coding appropriately to that level will maximize reimbursement. But making these determinations can be complex. Melanie Witt, RN, CPC, MA, and former program manager of the department of coding and nomenclature at the American College of Obstetricians and Gynecologists (ACOG) has provided us with a thorough explanation of the criteria for determining E/M levels.

This discussion is limited to office or other outpatient services for new or established patients. Office or outpatient implies that the treatment is given in the practice office or other ambulatory facility, and that the patient has not been admitted to a healthcare facility.

Drawing the Lines of E/M Care

The key components that determine the level of E/M service are history taken at the time of visit, extent of physical examination and medical decision-making. Medical decision-making is generally the area that causes the most confusionjust what are the differences between straightforward (S), low (L), moderate (M) and high complexity (H) medical decision-making?

Medical decision-making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by the:

1. number of possible diagnoses and/or management options;

2. amount and/or complexity of medical records, diagnostic tests and/or other information that is obtained, reviewed and analyzed; and

3. risk of significant complications, morbidity and/or mortality including co-morbidities associated with
the patients presenting problem(s), diagnostic
procedure(s) and/or the possible management options.

When selecting the overall complexity of medical decision-making, two of these three elements must be met or exceeded to qualify for a given type of medical decision-making.

The Risk Factor

There is also a final element in medical decision-making and that is risk. A risk table developed by the Health Care Financing Administration (HCFA) and the American Medical Association (AMA) determines the level of risk based on the highest level of risk in any of the three following categories.

1. Presenting problem(s) and disease process:

MinimalMinor problem (follow-up to treated vaginal yeast infection)

LowStable chronic illness (high blood pressure under control with medication)

ModerateUndiagnosed new problem (patient normally healthy complaining now of burning urination and blood in urine)

HighThreat to life or bodily function (ectopic pregnancy)

2. Diagnostic procedure(s) ordered:

MinimalLab tests/ultrasound

LowSuperficial needle biopsy

ModerateDeep needle or incisional biopsy

HighDiagnostic laparoscopy with risk factors

3. Management option(s) selected:

MinimalBed rest

LowOver-the-counter (OTC) drugs (e.g., cough medicine, Pepcid [...]

- Published on 2000-01-01