The Beginner’s Roadmap to E/M Coding

Are you employed by a practice requiring nurse practitioners to code their own charts? The family practice where I was previously employed relied on providers to select their own office visit codes. Often, I felt like I was shooting in the dark in my selection. If the visit ‘felt’ complex, I would assign a higher level code. If the visit seemed routine, I deemed a middle of the road CPT code sufficient.

Coding patient charts on a hunch is poor form in your practice (of which I, too, have been guilty!). Mistakenly selecting a more complex, higher paying code could land you in hot water with CMS or other insurance carriers. Choosing a code that doesn’t capture an appropriately high level of service means you aren’t being compensated adequately for the care you provide.

As nurse practitioners, we need to take a step back and familiarize ourselves with coding basics. Even if an outside entity is responsible for billing or coding in your practice, an awareness of coding practices helps keep your documentation up to par so you are reimbursed appropriately for the service you provide. The first step to coding correctly? Understanding the system.

What is E/M coding?

Evaluation and management coding, commonly referred to as E/M coding, is a system by which billing for medical services occurs. Healthcare providers or institutions assign codes to services provided for patients. These codes are then used by Medicare, Medicaid, or private insurance companies to compensate the provider for services rendered.

How do CPT codes fit in?

CPT, or Current Procedural Terminology, codes are the numerical indicators assigned to medical, procedural, and diagnostic services rendered by healthcare providers. CPT codes are established by the American Medical Association. The system of evaluation and management (E/M) coding relies on CPT codes to identify the service for which the provider must be reimbursed. An office visit, for example, has its own CPT code depending on the complexity of the visit.

What makes E/M coding so complex?

Not all services healthcare providers render are created equal. As a nurse practitioner, you’ve likely had patient visits so simple that completing documentation required more time than the patient encounter itself. Treating otitis media in a child without a significant medical history, for example, is quite simple. Other patient encounters aren’t so straightforward. Visits for patients with multiple chronic diseases, for example, can be quite time consuming and involved.

Recognizing this disparity in the complexity of patient encounters, office visits are assigned a variety of CPT codes. CPT code selection is guided by a set of criteria. This criteria helps medical providers determine the level of office visit complexity in order to assign an appropriate code. Documentation associated with the patient encounter must support selection of the CPT code.

Why is proper coding important?

The CPT code selected for the office visit determines the reimbursement rate for the encounter. CPT codes indicating higher levels of complexity reimburse the provider at a higher rate. Codes indicating lower levels of complexity are reimbursed at lower rates.

Improperly coded charts may result in overpayment subjecting the practice to an audit and penalties. ‘Undercoding’ results in lost revenue potential. Coding accuracy is essential for maximizing practice revenue within legal bounds.

What components account for CPT code complexity?

Several components of the patient encounter are taken into account in assigning the appropriate CPT code. They include:

  • Patient status – new vs. established
  • History of present illness
  • Review of systems
  • Medical/family/social history
  • Exam
  • Medical decision making

Items taken into account in making the CPT code determination must be documented in the corresponding patient chart.

There are certainly grey lines in E/M coding. Familiarizing yourself with the hard and fast rules and guidelines will help you make appropriate decisions when it comes to assigning CPT codes maximizing revenues and avoiding and audit and/or penalties.


Stay tuned…more to come on E/M coding this week on ThriveAP!