EM Coding Alert

Hint: Add examples to your presentation so clinicians can see exactly what you mean.

Evaluation and management (E/M) specifics are confusing even for seasoned coders, and educating providers can be tough.

Here are some tips for communicating the particulars of medical decision making (MDM) so providers and coders can work together to document care and receive pay for their work, shared by Emily Lomaquahu, CPC, CPMA, CEDC, during her presentation “Enhancing Provider Education” with Shea Lunt, CPC, CPMA, RHIA, for AAPC’s HEALTHCON 2025.

Start With the Basics

Even if an electronic health record (EHR) program incorporates all of a patient’s entire problem list into a visit note, the software probably does count for problems addressed. So, reviewing the actual AMA definition of problems addressed is important, Lomaquahu said.

“It’s a problem addressed when it’s treated or evaluated at the encounter. … So not every single problem on the problem list is considered unless it’s been addressed or is impacting the medical decision making in some way,” Lomaquahu said. “Also, problems managed by another provider, and referrals made with no evaluation, are not counted.”

If you’re using a slide deck in your session with providers, you may find it helpful to add the AMA’s table of Levels of Medical Decision Making (MDM) so providers can see which aspects of an encounter constitute each level of MDM. This is a great way to both head off and inspire questions: Clinicians can see the definitions for themselves and also form and ask more nuanced questions about MDM.

One thing the AMA chart lacks is examples, Lomaquahu noted. As you’re preparing your slides, you may find it helpful to add illustrative examples of each level of MDM, so clinicians can better see what distinguishes each level.

Educate on Categorizing Chronic Illnesses, Referrals, Dx Coding, Data

When trying to categorize chronic illness problems addressed in the documentation, providers may need some additional guidance. Lomaquahu said that the documentation should always indicate status in some way, like whether the condition is stable, exacerbated, or severely exacerbated.

“I know from looking at so many notes that sometimes it’s really hard to tell. When I don’t know, it ends up getting put under ‘stable,’ because I don’t see anything indicated it’s exacerbated,” she said.

Don’t be afraid to bring up referrals. “I highly doubt providers are just willy-nilly handing out referrals without any kind of evaluation. I’m willing to bet they’re doing an evaluation and then determining if it’s appropriate,” Lomaquahu said.

“I always mention to them to document that decision, document the evaluation, and say, ‘You know, due to this, I’m going to refer them here,’” she said.

Diagnoses are applicable to the problems addressed and count toward that element, but coders should report them only when the provider addresses them at the encounter. “You don’t want to be coding them if they’re not impacting the treatment or the management decisions,” she explained.

Another issue for which providers may need education is data, specifically regarding test analyses. The revised for 2021 E/M guidelines say that data can be used in MDM: “The data element itself may noy be subject to analysis (e.g., glucose), but it is instead included in the thought processes for diagnosis, evaluation, or treatment.”

This can be hard to explain, Lomaquahu said, but coders need to see that the test serves as part of the assessment plan or part of the MDM. Providers may think that because they ordered a test, it’s obvious that the data produced would be part of their MDM; but to count it, coders really need to see that information in the note and how it relates to the MDM.

Providers should also understand that tests ordered are presumed to be analyzed when the results are reported, she said. “The provider is going to get credit for that test at the time of the order. Oftentimes they’ll order it during the encounter, and then maybe the results come back later. But they’re going to get credit for it when it’s ordered and only that one time.”

Coders need to know whether tests are classified as single or multiple, based on the CPT^® code set. A panel like a complete blood count (CBC) has multiple data points, but it’s considered one CPT^® code, and coders should count it accordingly.

Prepare Answers in Advance for These FAQs

FAQ 1: Do previously diagnosed medical conditions count as chronic if the conditions are new to the provider?

“It does not matter how long the provider has been treating that condition. If it’s a condition that is generally accepted as lifelong or chronic, like diabetes, it’s considered chronic,” Lomaquahu said.

FAQ 2: Should coders determine whether a patient’s condition or illness is stable or worsening?

Coders worth their salt know that providers are responsible for determining the clinical decisions for patients. It’s up to the provider to make this call.

FAQ 3: If a provider determines that a condition or sign/symptom requires a referral, does that determination count as a problem addressed for the encounter?

It depends on the situation, but regardless, coders need the provider to document that evaluation and the decision to send the patient to the appropriate referral.

FAQ 4: Can an encounter with a patient who has several conditions and takes several medications — though none are life-threatening — be considered high risk MDM?

While this type of encounter may be coded as a higher level due to the time involved, for MDM, you need to look at whether the chronic illnesses have severe exacerbation or progression, or whether they’re posing a threat to life or bodily function. “We can’t take all these different problems addressed that are in the low and moderate category and stack them on top of each other to make it high,” Lomaquahu explained.

Rachel Dorrell, MA, MS, CPC-A, CPPM, Development Editor, AAPC