Medical Coding and Billing Training

. How to do EM coding perfectly?
E/M coding is the process by which physician-patient encounters are assigned five digit CPT codes for the purpose of billing medical claim. CPT (current procedural terminology) codes are the numeric codes which are submitted to insurers for payment. Every billable procedure has its own individual CPT code.
For accurate & error free E/M coding, read the medical record with full attention towards the following.
• Establish first the place of service. Since it defines the correct category from where we have to use the code e.g. Office, Inpatient, Observation etc.
• Check for the age of the patient (required for critical care coding)
• Decide the sub category for E/M coding whether the patient is new or established.
• Check the number of key components required for coding in the sub category selected.
• If codes are not based on key components check for contributory factors like counseling (time spent), Coordination of care (time spent), nature of presenting problem, or time (critical care face to face time).
2. How to indentify new patient versus established patient?
According to CPT a new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.
An established patient is one who has received professional services from the physician, or another physician of the same specialty who belongs to the same group practice within the past three years.

Group practice means a group of providers in a facility or clinic operating under the same tax ID.
3. E/M coding HPI calculation
For decision regarding the level of history component, individual elements (location, duration, severity, quality, timing, context, modifying factors & associated signs & symptoms) for history of present illness are to be counted accurately.
• If only three elements of history are present in the history then it is considered as brief history.
• History with more than three elements is considered as Extended HPI

4. Importance of ROS in E/M coding
ROS is an inventory of body systems done by physician during the process of recording the HPI. It helps define the problem, differential diagnosis, or identify needed testing etc. Importance of ROS can’t be ignored since it is also one factor which decides the level of history. It is not necessarily done by the physician. It can be recorded by other staff of physician’s office or by patient themselves on ROS questionnaire. However, the physician must review the information and comment on pertinent findings in the body of the note.

Note: The above information is for study purpose, the author doesn’t guarantee the validity and authentication of the subject, please refer to CPT Coding Guidelines
CPT is the registered Trademark of the American Medical Association.

info@medesun.com

Author: Dr Yaseen, MD, CPC

Faculty Medical Coding

http://www.medicalcodingexperts.com

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