E&M Audit and Training

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General Information

The billing conventions for evaluation and management (E/M) services in the teaching setting are based on what is defined under the guidelines as “key components”.

Those components are history, physical examination, and medical decision making. A fourth component, time, is applicable for visits that are mainly counseling and/or coordinating care and is considered to be the controlling element under those circumstances.

Depending on the site and type of service, the physician must meet stated criteria on all three key components or two of the three key components.

Evaluation & Management CPT Codes are 5-digit numeric codes which are found in the Evaluation and Management (a.k.a. E&M) section of a CPT-4 book.

This section is most often found at the front of CPT-4 books, regardless of the publisher or vendor, since this is the section most frequently used by providers of all specialities.

The E&M section contains all the different ways a provider can bill for evaluations of a patient that do not require a procedure. Examples include office visits, consultations, and annual physicals.

The E&M Section of the CPT-4 Book Contains the Following:

  • Office & Outpatient Services
  • Observation
  • Inpatient
  • Consultations
  • ER
  • Critical Care
  • Neonatal Intensive Care
  • Domicillary, Rest Home, Custodial Care
  • Home Services
  • Prolonged Services
  • Case Management Services
  • Care Plan Oversight
  • Preventative Medicine Services
  • Newborn Care
  • Special Evaluation & Management Services
  • Other Evaluation & Management Services

The physical examination is another key component of E/M services. Under current CMS guidelines, there are two options to meet documentation requirements:

1. the 1995 guidelines

2. the 1997 variation

CMS has instructed regional carriers to audit documentation against both sets of guidelines and allow the one most advantageous to the physician. This course will focus exclusively on the 1995 guidelines.

For purposes of examination, the following body areas are recognized:

  • Head, including the face
  • Neck
  • Chest, including breasts and axillae
  • Abdomen
  • Genitalia, groin, buttocks
  • Back, including spine

What’s included in our program:

  • E&M Trending
  • Review of documentation
  • Report to show coding accuracy
  • 1-on-1 meeting with the reviewer to discuss the findings

“Excellent course. Very informative. Thank you! “

~ Monica Rao, DMD, Webster, MA