Running head: EVALUATION AND MANAGEMENT CODING 1

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Details required in determining an accurate E/M code:

To come up with an accurate E/M code, the following details should be taken into keen

consideration:

1. The type of patient: patients can be classified into two categories—new or established—

based on whether or not they have had a previous interaction with the service giver.

 New patients are individuals who have never received any form of service from

a given physician or any other physician within the same line of specialization

over the last 3 years.

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 Established patients are individuals who have received a form of professional

service from a given physician or any other physician within the same line of

specialization over the last 3 years.

For our discussion, I will consider the case of an established patient.

2. Service setting: E/M services are furnished at diverse settings within a given facility, or at

different facilities altogether. The settings may include the inpatient wing of a hospital,

outpatient wing of a hospital, a skilled nursing facility, and the emergency department of

the hospital.

For this particular discussion, I will consider the case of an E/M service furnished at a

skilled Nursing Facility (SNF) and an E/M service furnished at an adult intensive care unit.

3. The level of the E/M service provided: since E/M service codes are grouped into different

levels and categories, it is vital to determine the complexity of the service provided in order

to come up with an accurate code. Complex services call for higher levels of coding in the

suitable class. To select the suitable level of E/M service, the NPP, NP, or PA needs to take

care of three important components: history provided by the patient, type of evaluation

performed on the patient, and the level of complexity in determining a diagnosis for the

patient.

Scenario to illustrate a physician providing an E/M service to an established patient in a

SNF:

Having been previously diagnosed with cirrhosis of the liver in the initial visit, say, four years ago,

a patient is admitted to a skilled nursing facility with the following signs and symptoms:

 Changes in personality.
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 Accelerating heartbeats.

 Confusion in day-to-day matters.

 Frequent dizziness.

 Loss of body and upper limbs mass.

 Buildup of fluid in feet, legs, and ankles—edema.

These, among other signs and symptoms, are indicative of a progressing case of liver cirrhosis.

From the review of systems, it is apparent that the patient’s liver tissue is gradually being replaced

by a scar tissue which is fibrous. Regenerative lumps/nodules are also appearing as the patient’s

liver tries to cure the damages. The service provider then performs a focused evaluation on the

affected organs including, but not limited to, the feet, ankles, legs, the heart, and the liver. Since

the condition of the patient has been monitored and the patient is relatively stable, there’s no

requirement to review data from lab/diagnostic results; therefore, the service provider together

with the patient may agree to a straightforward medical decision of correcting the resulting

complications as a treatment for the underlying cause of the complications is continuously

administered.

Accurate CPT code for the E/M service furnished:

The accurate CPT code to be reported by the NPP, NP, or PA would then be CPT code 99307:

accompanying nursing facility care, per day, for the assessment alongside management of the

patient, requiring a minimum of two components among these three crucial components (interval

history which is problem-focused, problem-focused evaluation, and a clear-cut medical decision).

Scenario to illustrate a physician providing an E/M service to an adult in a critical care unit:
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For this scenario, I will maintain the case of the patient with the liver cirrhosis discussed above.

With time, the liver cirrhosis progresses further. The liver is gradually impaired and the life of the

patient is in imminent danger. The condition of the patient has adversely deteriorated as the liver

is significantly damaged and as such, it cannot perform vital functions in the body.

The signs and symptoms of this severe condition include:

 Lethargy

 General weakness due to anemia

 Appetite loss

 Constant fatigue

 Heart failure that is congestive

 Hyperkalemia, among other symptoms.

Based on the condition of the patient and the imminent failure of a vital organ—the liver, the

patient is taken to the intensive care unit where highly complex decisions to evaluate, control, and

support the liver to avoid further deterioration of the condition of the patient are made. After

moving the patient to the ICU, the physician spends one and a half hours giving direct and intense

medical care for the patient who is critically ill.

Accurate CPT code to be reported:

In total, the physician spends 90 minutes attending to the patient who is critically ill; therefore, the

physician will report two CPT codes for the services furnished in the ICU.

1. The first code the physician will report is the CPT code 99291: critical care, evaluation and

management of the critically ill patient for the first 74 minutes.

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2. Then the physician will record the CPT code 99292: critical care, evaluation as well as

management of the patient who is critically ill for the minutes above 74 in intervals of 30

minutes.

References

Hughes, D. R., Jiang, M., & Duszak, R. (2015). A comparison of diagnostic imaging ordering

patterns between advanced practice clinicians and primary care physicians following

office-based evaluation and management visits. JAMA internal medicine, 175(1), 101-107.

Kanwal, F., Asch, S. M., Kramer, J. R., Cao, Y., Asrani, S., & El‐Serag, H. B. (2016). Early

outpatient follow‐up and 30‐day outcomes in patients hospitalized with

cirrhosis. Hepatology, 64(2), 569-581.

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Silva, P. E., Fayad, L., Lazzarotto, C., Ronsoni, M. F., Bazzo, M. L., Colombo, B. S., ... &

Schiavon, L. L. (2015). Single‐centre validation of the EASL‐CLIF Consortium definition

of acute‐on‐chronic liver failure and CLIF‐SOFA for prediction of mortality in

cirrhosis. Liver International, 35(5), 1516-1523.