# Need help with E/M



## hydster (Nov 15, 2011)

I am a newly certified coder and I have a question about E/M. I went on a job interview and while at the interview they gave me a couple of pages with different but real scenarios. Honestly I was stumped and cannot figure out how I passed the CPT class I was enrolled in or how I passed the national exam not knowing how to do E/M coding (specifically determining  the level of E/M Service)very well. 

In my class when we were given assignments or tests the determination of service levels were given ie: doctor did expanded problem focused exam, comprehensive history and the MDM of moderate complexity. When I went for this job interview there was nothing like that on the sheets I was to code from but I have NO idea how to figure this out and I worry that if I don't know how to do it I will never be successful as a coder.

I asked one of the staff at school about it and the only thing she told me was to get the study guide and read that. I don't have the extra cash to buy the study guide especially for one paragraph (that's what the staff member at my school said it consisted of) and I already passed the CPC exam. I don't know why it wasn't something that was taught considering it seems to be a huge part of coding. Can anyone tell me how to figure that out so I can find a decent job and not feel like a failure?

Thanks


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## cyalden (Nov 15, 2011)

Check out E/M University.  They have some very useful tools.  

http://emuniversity.com/index.html


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## btadlock1 (Nov 15, 2011)

hydster said:


> I am a newly certified coder and I have a question about E/M. I went on a job interview and while at the interview they gave me a couple of pages with different but real scenarios. Honestly I was stumped and cannot figure out how I passed the CPT class I was enrolled in or how I passed the national exam not knowing how to do E/M coding (specifically determining  the level of E/M Service)very well.
> 
> In my class when we were given assignments or tests the determination of service levels were given ie: doctor did expanded problem focused exam, comprehensive history and the MDM of moderate complexity. When I went for this job interview there was nothing like that on the sheets I was to code from but I have NO idea how to figure this out and I worry that if I don't know how to do it I will never be successful as a coder.
> 
> ...



I really don't like the way that E/M is taught for the CPC exam - it doesn't take medical necessity into account at all, and basically teaches you to code based solely off of the amount of documentation present. You need to know how to code E/M properly. E/M University is a good resource, as are the MAC's. Mine's Trailblazer - here's their E/M page: http://www.trailblazerhealth.com/Publications/Default.aspx?ACTION=search&DomainID=1
Check out all of their publications, and read over the 1995 and 1997 documentation guidelines. This one is especially helpful, in my opinion: http://www.trailblazerhealth.com/Publications/Job Aid/DocumentingComponentsEOV.pdf


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## hydster (Nov 15, 2011)

THANK YOU both so much!!!! I will check those sites out!!!


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## nursey9@aol.com (Nov 15, 2011)

The first thing you have to do is figure out where the patient is and if they are new to the practice or an established patient. Each section has it's own paranthetical notes before the codes. The new patient section states that you have to have 3 out of 3 (history, exam and medical decision making ) on the same level. The established patient only needs 2 of 3. 
You don't need another book! Open up your CPT and turn to E&M and read the directions for each section and the coding tips. They are very helpful. Make notes in your book.
For the new patient, if you have 2 on 1 level (say history and exam) and the 3rd on another, drop to the lowest code. It has to meet or exceed to be able to use the code.
Hope I didn't confuse you. I'm new too and was not shown how to use the book.
Hope this helped : )
jeannie


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## btadlock1 (Nov 15, 2011)

nursey9@aol.com said:


> The first thing you have to do is figure out where the patient is and if they are new to the practice or an established patient. Each section has it's own paranthetical notes before the codes. The new patient section states that you have to have 3 out of 3 (history, exam and medical decision making ) on the same level. The established patient only needs 2 of 3.
> You don't need another book! Open up your CPT and turn to E&M and read the directions for each section and the coding tips. They are very helpful. Make notes in your book.
> For the new patient, if you have 2 on 1 level (say history and exam) and the 3rd on another, drop to the lowest code. It has to meet or exceed to be able to use the code.
> Hope I didn't confuse you. I'm new too and was not shown how to use the book.
> ...



Believe it or not, there's a LOT more to it than that - like, how you determine what the level of the history/exam/MDM should be, based on the documentation. Remember that in real life, no one tells you 'this is a detailed history' or 'this is an expanded problem focused exam' - you have to know how to identify whether or not the doctor gave an extended History of Present Illness (HPI), performed an extended review of systems, and the required problem pertinent Past, Family, Social History elements, to consider the history detailed, or if he examined enough body areas/organ systems, or bulleted exam criteria to meet the definition of a particular level of exam. MDM is also comprised of 3 different factors that have to be considered; and on top of all of that, you're only supposed to report the highest level of service_ required _to assess and treat the patient's presenting problem (so, don't bill a 99215 for a cold, just because the doctor documented enough elements to meet the requirements - it's not medically necessary) - it's actually quite complicated.


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## rthames052006 (Nov 15, 2011)

hydster said:


> I am a newly certified coder and I have a question about E/M. I went on a job interview and while at the interview they gave me a couple of pages with different but real scenarios. Honestly I was stumped and cannot figure out how I passed the CPT class I was enrolled in or how I passed the national exam not knowing how to do E/M coding (specifically determining  the level of E/M Service)very well.
> 
> In my class when we were given assignments or tests the determination of service levels were given ie: doctor did expanded problem focused exam, comprehensive history and the MDM of moderate complexity. When I went for this job interview there was nothing like that on the sheets I was to code from but I have NO idea how to figure this out and I worry that if I don't know how to do it I will never be successful as a coder.
> 
> ...



Also, depending on who your MAC is they provide some educational sessions. My MAC is Highmark Medicare and they are very good about providing e/m education through out the year.  

Matter of fact, if you get on the CMS website you can attend webinars pertaining to e/m coding, they have a basics class and an advanced class for e/m and the best part is they are FREE and you earn CEU's.  

I know some people who are not in J12 area still listen in on e/m educational sessions provided by Highmark.

Good luck!  

The books can really only teach you so much, you've gotta put yourself out there. Even try an E/M Bootcamp.

Just a few thoughts 

Here is the link to Highmark Medicare events:

https://www.highmarkmedicareservices.com/em/index.html


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## hydster (Nov 15, 2011)

btadlock1 said:


> Believe it or not, there's a LOT more to it than that - like, how you determine what the level of the history/exam/MDM should be, based on the documentation. Remember that in real life, no one tells you 'this is a detailed history' or 'this is an expanded problem focused exam' - you have to know how to identify whether or not the doctor gave an extended History of Present Illness (HPI), performed an extended review of systems, and the required problem pertinent Past, Family, Social History elements, to consider the history detailed, or if he examined enough body areas/organ systems, or bulleted exam criteria to meet the definition of a particular level of exam. MDM is also comprised of 3 different factors that have to be considered; and on top of all of that, you're only supposed to report the highest level of service_ required _to assess and treat the patient's presenting problem (so, don't bill a 99215 for a cold, just because the doctor documented enough elements to meet the requirements - it's not medically necessary) - it's actually quite complicated.



Yes! This is exactly what I am struggling to figure out the level and how to tell which code to use when it's not spelled out. I really wish I would have been taught how to do this instead of trying to figure it out on my own. The rest of it I understand but how to code these areas confounds me for some reason. Thank you though to all of you who replied. I will hopefully figure this out and at some point get a job!

Rthames: I don't know how to find out who my MAC is. I wasn't really taught that either. My friend and I had to basically teach ourselves ICD-9 so it shouldn't shock me I don't know how to find my MAC but it's disheartening for sure!!

Thanks again though!


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## btadlock1 (Nov 15, 2011)

hydster said:


> Yes! This is exactly what I am struggling to figure out the level and how to tell which code to use when it's not spelled out. I really wish I would have been taught how to do this instead of trying to figure it out on my own. The rest of it I understand but how to code these areas confounds me for some reason. Thank you though to all of you who replied. I will hopefully figure this out and at some point get a job!
> 
> Rthames: I don't know how to find out who my MAC is. I wasn't really taught that either. My friend and I had to basically teach ourselves ICD-9 so it shouldn't shock me I don't know how to find my MAC but it's disheartening for sure!!
> 
> Thanks again though!



You can use any MAC's info - it's all basically the same. But, it's based on geographical location - to find out which one's yours, go here:http://www.cms.gov/MedicareContractingReform/05_PartAandPartBMACJurisdictions.asp#TopOfPage
Then, if there's not a link, Google it.


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## MnTwins29 (Nov 16, 2011)

*Maybe I am naive here....*

but for many visits, doesn't the nature of the presenting problem or the diagnosis take care of medical necessity by bumping down the MDM level, thereby lowering the overall code assigned?   Brandi's statement of not assigning a 99215 to a cold is absolutely correct.   But unless the doctor is documenting the patient's history since 1927, and examining every part of her body, how would you get 99215?  How would this diagnosis possibly even get close to a high level of MDM?   You couldn't get 4 points on nature of the presenting problem, it can't be a high level of risk, and could you really get 4 data points?   Realistically, I don't see how it would happen, even if you copy and pasted every visit the patient ever did.

I understand Brandi's point, and I concurr with the meaning of the statement, but I just can't see it in the real world.   Now, if you say that these kinds of actions can result in overuse of *99214* with colds, then I say that is a stronger possibility and more of a problem that can arise.


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## btadlock1 (Nov 16, 2011)

MnTwins29 said:


> but for many visits, doesn't the nature of the presenting problem or the diagnosis take care of medical necessity by bumping down the MDM level, thereby lowering the overall code assigned?   Brandi's statement of not assigning a 99215 to a cold is absolutely correct.   But unless the doctor is documenting the patient's history since 1927, and examining every part of her body, how would you get 99215?  How would this diagnosis possibly even get close to a high level of MDM?   You couldn't get 4 points on nature of the presenting problem, it can't be a high level of risk, and could you really get 4 data points?   Realistically, I don't see how it would happen, even if you copy and pasted every visit the patient ever did.
> 
> I understand Brandi's point, and I concurr with the meaning of the statement, but I just can't see it in the real world.   Now, if you say that these kinds of actions can result in overuse of *99214* with colds, then I say that is a stronger possibility and more of a problem that can arise.



That example was meant as hyperbole, rather than realistic -I was aiming to illustrate the point that medical necessity has to be taken into consideration, when selecting the E/M level..._ but _I have seen real examples that are comparable (with enough documentation to satisfy the technical requirements of 99214/99215, for conditions like sinusitis). It's pretty easy to over-document with EMR prompts doing most of it for them.


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## MnTwins29 (Nov 16, 2011)

*Hyperbole....thanks!*

Sometimes in these forums, or in e-mails, it can be hard to separate hyperbole from "real world", humor from anger and the like.    I don't discount the medical necessity angle - I have just found in my chart reviews I have more troubles with colds, pharyngitis, epitaxis, etc being assigned 99214 because of overdocumentation in the History and Exam instead of these resulting in 99215.   And, IMO, this many 99214s is more problematic than assigning a 99215 to one visit for any one of these problems, because the former happens MUCH more frequently.


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## txkimberco (Aug 17, 2014)

*Terrible at E/M*

I have the exact same problem.  Passed the course, passed the exam.   Don't understand a single concept of E/M


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## CatchTheWind (Aug 18, 2014)

txkimberco and hydster: I would be happy to share my E/M worksheet with you. It literally walks you through the E/M coding process step by step.

Just click on my profile and choose the tab that says "contact info."


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## mass31 (Aug 21, 2014)

I have this problem too passed my class passed the exam now working on practicode and I can't get a single E/M question correct because in my class it was spelled out for you this is a detailed history detailed exam and MDM is moderate


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## erjones147 (Aug 21, 2014)

I fully agree with Brandi's statement about "overdocumenting" thanks to EHR clickies. 

There is just no way I'm even considering coding a 4 without either a new chronic problem, two worsening chronic problems, or three chronics that have had their status checked clearly in the note - I don't care how good the HPI or exam is - and THEN I check for labs ordered, meds adjusted, etc., THEN I'll go back and see if the history and/or exam supports a 4.

My clinic director is on me all the time to push more 4's through, but I can't make chicken salad out of chicken spit. Sometimes, a cold is just a cold

I really wish someone would just nuke the 95 and 97 guidelines and rewrite them from scratch. I guess I wouldn't make a very good CEMC


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