Evaluation and management (E/M) coding is a key component of the medical coding and billing process. Why? Because it is used to communicate the level of complexity and intensity of the medical services provided by healthcare professionals.
As a medical coder, it is crucial to understand the nuances of E/M codes as they provide a standardized way to determine the reimbursement level for the time and effort spent by healthcare providers. Code inaccurately and it may lead to either underbilling or overbilling. Both have dire consequences:
Underbilling = Revenue Loss
Overbilling = Audits, Fines, and/or Legal Action
This blog dives deep into the world of E/M coding, exploring the significance of E/M codes, the structure, key components, challenges, and recent updates.
What are E/M codes?
E/M codes are a subset of CPT codes established by the American Medical Association (AMA) to represent services provided by physicians to assess and manage a patient’s health. They range from 99202 to 99499 and include services like office visits, hospital visits, home services, and preventative medicine care.
What sets them apart from other CPT codes?
Rather than focusing on procedures and tests, E/M coding focuses on cognitive services provided by healthcare providers.
Significance of E/M Codes in Healthcare RCM
E/M codes are vital in healthcare revenue cycle management for several reasons, such as:
- Accurate Billing: E/M codes provide a standardized framework for documenting and coding the services provided during patient encounters. The result? Accurate billing and minimized undercoding or overcoding.
- Reimbursement Determination: Each E/M code signifies a specific level of complexity and intensity of the services provided, which directly affects the reimbursement amounts.
- Compliance: There have been rules and guidelines set in place for E/M coding by the Centers for Medicare & Medicaid Services (CMS) and the American Medical Association (AMA). Compliance with these regulations is essential to avoid penalties, audits, and potential legal issues.
- Data Analysis and Research: As we know, E/M codes provide a standardized framework for documenting and reporting patient encounters. This standardization allows healthcare providers to collect this data and analyze it to identify patterns and conduct research studies. The outcome? Constant improvement of the healthcare system.
The Structure of E&M Codes with Examples
Key elements of E/M code structure:
- CPT Code Range: 99202 to 99499.
- Service Type: Office visits, home services, consultations, etc.
- Patient Type: They differentiate between new and established patients.
- Setting of Care: Reflects the location where the service was rendered.
- Complexity of Encounter: Considered on the basis of factors such as history, examination, medical decision-making, and more.
- Time: For some E/M codes, the total time spent on an encounter is a factor in determining the level of service.
- Medical Decision Making or MDM: E/M codes can be selected on the basis of the level of medical decision-making required during the patient encounter.
Examples of common E&M codes:
| 99202–99205: New Patient Office/Outpatient Services | |
| 99202 | Straightforward MDM, or minimum 15 minutes. |
| 99203 | Low MDM, or minimum 30 minutes. |
| 99204 | Moderate MDM, or minimum 45 minutes. |
| 99205 | High MDM, or minimum 60 minutes. |
| 99211–99215: Established Patient Office/Outpatient Services | |
| 99211 | Straightforward MDM, or minimum 10 minutes. |
| 99213 | Low MDM, or minimum 20-29 minutes. |
| 99214 | Moderate MDM, or minimum 30-39 minutes. |
| 99215 | High MDM, or minimum 40-54 minutes. |
Common Challenges of Evaluation and Management (E/M) Coding
Below are the key challenges of E/M coding:
- Complexity: Since E/M coding relies heavily on history, examination, and medical decision-making (MDM), it can be a little challenging for even experienced medical coders to navigate. The specific requirements for each level of service can be confusing, leading to errors and misinterpretations.
- Subjectivity: There’s no consensus about the specific requirements of E/M documentation. This allows for subjective interpretations and creates unproductive disputes over correct coding. For instance, determining the ‘level’ of medical decision (e.g., low, moderate, high) involves judgment calls that may vary from coder to coder/provider to provider.
- Inconsistencies: One major problem with E/M coding is that the rules of leveling services are not always clear. This makes it difficult to determine the appropriate level of service for a particular encounter.
Commonly Used E/M Terminology
Qualified healthcare professional: Someone who is qualified to perform professional service within their scope of practice. E/M code descriptors and rules often refer to “physicians and other qualified healthcare professionals.”
Clinical staff member: An individual who works under the supervision of a physician or other qualified healthcare professional and is allowed by the law to perform or assist in the performance of a specific professional service.
Professional service: A face-to-face service by a physician or other healthcare professional who can report E/M codes.
New Patient: A patient who has not received any face-to-face services within the past three years from the physician or qualified healthcare professional providing the current E/M service or from any other physician or qualified professional of the same specialty.
What is “Total Time” in E/M coding?
When assigning E/M codes, medical coders have to consider one very critical aspect – the total time. Total time includes both face-to-face and non-face-to-face time spent by the provider on the care of a patient on the date of the encounter.
It includes tasks like:
- Prepping to see the patient
- Obtaining and/or reviewing separately obtained history
- Ordering medications, tests, or procedures
- Counseling and educating the patient/family/caregiver
- Care Coordination, and more
What it doesn’t include — is travel time, time spent on any procedure that is being billed separately, and teachings unrelated to that specific patient.
Recent Changes in E/M Coding 2025
The recent changes in E/M coding were driven by a desire to simplify documentation, reduce administrative burden, and better align coding with current patient care practices.
Key changes include:
- Simplified Code Selection: The focus has now shifted from scoring individual components to selecting code levels based on MDM or total time spent.
- Less Documentation Burden: Providers are now encouraged to document based on their professional judgment rather than relying on rigid history and exam requirements.
- Home Care Services: According to AAPC, E/M codes for home care services now include any patient residence, including assisted living facilities.
Tools and Resources for E/M Coders
Now that we have understood the importance of E/M codes in medical billing and coding, it’s safe to say that there’s no room for errors.
As a medical coder, you should spend a lot of time understanding the nuances of E/M coding. One misstep could lead to serious consequences: incorrect billing can trigger criminal penalties, while knowingly submitting false claims for federal healthcare payments amounts to Medicare fraud.
To stay on top of your E/M coding game, you should be familiar with various tools and resources available. The AMA, CMS, and AAPC provide excellent resources and learning tools for CME, CE, and self-education.
Evaluation and Management (E/M) Coding with Aidéo
As the healthcare industry continues to grow, the role of E&M coding is only going to become more and more complex. Recent studies have shown that 19% of E/M services are undercoded, short-charging physicians by $14,250 annually!
But you don’t have to worry about your revenue slipping away. Aidéo, powered by its AI coding platform—Gemini™, is equipped to deal with your E/M coding requirements.
Through an exclusive partnership with AAPC, Gemini™ integrates with AAPC’s E/M coding calculator. This way, your coders have access to a wealth of information, including the latest E/M codes, time-based coding guidelines, MDM definitions, and more, on a single platform.
Ready to see how Gemini™ and AAPC tools can transform your workflow? Request a demo today!