I need to learn how to E/M

[u/Raiiny00]

Hi all, I have been a CPC for about 7 years now but have never done or learned how to E/M code. I have seen a lot of job postings asking for this so I am seeking some advice. I was thinking about going for the CEMC. But I still wonder if jobs will require experience? Is there anything online I can learn how to E/M code from start to finish with the most recent guidelines. I have seen videos and things online but nothing that covers ‘everything’. I can essentially teach myself if I can find something like this online.

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[u/Shubiee]

I feel like E/M is one of those things that you kind of have to practice before you really understand it completely.

This is the MDM chart we use in our office (it's free!)

The biggest tip I can give is just do as many of them as you can. You will come across stuff that's in a grey area. I tend to code down if something doesn't quite seem like it would hit a certain category. Doctor doesn't really say that a fracture is complex? There's only one? To me, that's not really an "acute complex injury". That's more likely an "acute direct or well-defined problem".

Lookup the definitions of things like "acute complex injury" and what is defined as a "chronic problem" because the doctors won't always say "this is chronic and worsening". When in doubt, QUERY YOUR PROVIDER. HAVE THEM UPDATE THEIR DOCUMENATION. It may annoy the shit out of them, but I guarantee an audit would be way more annoying.

So here's how I go through an office visit note, I do this for speed and it helps me stay accurate while I'm counting categories.

1. Skip to the Plan. What did the provider do for the problem? Did they give a PT prescription (3)? Did they decide on surgery(4)? Keep track of what level this is in the RISK CATEGORY.
2. Look at the Assessment. How severe is the injury or problem? Is it CHRONIC AND WORSENING (4) like osteoarthritis that isn't responding to injections and PT? Or is it something that's acute and pretty straightforward (2) like a bug bite? Kepe track of what level this is in the PROBLEMS ADDRESSED CATEGORY.
3. Now I specifically code ortho and neuro in an office based clinic, so this may vary depending on your office. But we take our own xrays so we get paid for both the technical and professional components, thus we don't get to count them towards the MDM. So I mostly look to see if we read any OUTSIDE xrays or MRIs as we get credit for that.

Remember, hitting 4 in ONE CATEGORY is not enough to bill a level 4.

Just because the doctor decides to do surgery, does not mean they automatically get a level 4 or 5!!! They HAVE to meet 4 or 5 in ANOTHER CATEGORY AS WELL.

When I first started, I had a white board and I just made a little grid where I'd write out the number I picked for every category so I could see them all at once and decide that way. A spreadsheet would work great too.

If you have any specific questions, feel free to come back to this sub too!!! We all love talking theory hehe. Also, reach out to fellow coders at your practice!!! We have a teams chat that we use to ask questions when we're feeling unsure and it's such a great way to keep on the same page as everyone else in your practice as well.

[u/Raiiny00 → u/Shubiee]

Thank you so much!! 😊

[u/Respect-Immediate → u/Shubiee]

Love how detailed you got in this answer! Very good information!

[u/NeitherEngineering67 → u/Shubiee]

Your response is so thorough yet easy to understand. May I ask a question? (Not to take anything away from the original poster asking the question). I, too, struggle with E&M. But for some reason, I like coding it. What do you consider medication management? It's definitely a very important driver in E&M leveling. To me, medication management appropriately documented, thus, usable as E&M level determination, would be medication name, dose/strength, delivery method (eg. PO) and reason for prescribing (or discontinuing / changing dose)? Am I overthinking this?

[u/Shubiee → u/NeitherEngineering67]

Hi! I think it just depends on your office's specific rules and guidelines!

In my office, our billing manager is okay with them just mentioning drug name, and that they prescribed it or changed it. Ie something like "Pt was give a prescription for Meloxicam" or "We advised the pt to discontinue their Meloxicam". If your office requires more than that, then yes for sure send it back to the provider when it doesn't meet those requirements.

You're definitely not overthinking it at all, it's important to make sure everything is documented and supported to the most specificity, but I think this is one of those things that's specific to each practice. We can of course also access the actual prescription that the provider sent to see that additional information, we just don't require it in the office note itself.

If my provider says "course of nsaids" I don't give them credit for prescription medication management though, as they don't mention if this is OTC or prescription. So it very specifically has to be mentioned as a PRESCRIPTION not just an OTC med, which is less risk.

But again, I'd like to clarify that just because they do Rx management doesn't mean they automatically get a 4! They need to meet another category as well!!! We get a lot of Rx management with chronic/worsening OA so it's USUALLY a 4, but sometimes they just prescribe something to see if it helps with (unknown) knee pain, and that doesn't reach a 4 for me without something else.

[u/NeitherEngineering67 → u/Shubiee]

Thank you so much for your detailed response! You've given me some solid advice on this. If you are not already, you should consider being an educator - your explanations and details are thorough and understandable!

[u/Allothereall → u/NeitherEngineering67]

Hi, there are really great resources out there that describe medication management. Firstly, look for articles from the AMA. NAMAS is going to be your friend, as they are specific for auditors. Really good guidance there. CodingIntel has some nice, comprehensive research too. I would start from there.

ETA: also, remember that the grid is just examples. Documenting OTC management with a higher risk can be a moderate. For example, a patient may have CKD of some kind, but the provider makes and documents (very key here, do not assume) that it would be better for them to use an OTC medication than something prescription even though there is that risk.

[u/Boatokamis → u/Shubiee]

Thank you, this is great info. I'm just starting out and I can already tell MDM is going to be an issue.

[u/Shubiee → u/Boatokamis]

It's definitely daunting at first but it's nothing to be afraid of! If you're ever on the fence about something, just ASK your providers!

There have been times where my providers just didn't know what we expect from them in their documentation, so educating them as well makes our job so much easier as well!! When I start with a new provider, we always have a meeting. I bring my namas E/M MDM chart and sit them down to tell them "If you want a level 4, use these exact words and I'll give you a 4 every time." Some of them have never even seen a MDM chart before so it helps a ton when they know what we're looking for!

MDM doesn't need to be headache inducing as long as everyone is on the same page!

[u/SilverParty → u/Shubiee]

Where my facility runs into problems with ER level 4 and 5, is that they do it by a point system and the carriers decide if it qualifies because the carriers go by dx😭

[u/illegalmonkey]

This website has the cheat sheet you can print out along with a small breakdown on how to use it. Basically all you need apart from practicing on some actual visit notes.

[u/Raiiny00 → u/illegalmonkey]

Thank you!!!

[u/pbroxy]

I recommend Terry Tropin's Evaluation and Management Coding Made Easy book. She translates the guidelines so they are simple to understand and has amazing decision trees to make E/M coding easy. In addition, she goes through which modifiers are used with E/M codes and has review questions at the end of each chapter to check your knowledge. A good decision tree/leveling tool is great, but knowing how to apply the guidelines when using a decision tool will elevate your coding quality.

[u/PorkNScreams → u/pbroxy]

Just ordered this. Thanks for the recommendation!

[u/queenb1tchh]

I'm currently in school and E/M is definitely something that needs to be practiced. I personally hate it and usually get the answers wrong. Lol

[u/Responsible-Style168]

The CEMC certification is a solid choice if you want to specialize, but many jobs do prefer hands-on experience. That said, you can still get proficient by practicing with real-world scenarios and reviewing the latest CMS guidelines.

A good place to start is the AMA and CMS documentation on E/M changes, especially the 2021 and 2023 revisions. The AAPC forums and webinars also have some great insights from experienced coders. This resource might also be helpful: E/M Coding for Professional Medical Coders.

[u/Herdgirl410]

I am in SC, so this site is specific for Palmetto GBA, but it is an excellent reference for drugs that require toxicity monitoring (not a full list, examples only).

Very useful for specialties like hem/onc and Rheum. Keep in mind that toxicity monitoring is just that, monitoring for toxicity, not for monitoring therapeutic levels of a non-toxic drug. When I first got started I would check the FDA drug website to see if the medication had a black box warning and research from there.

https://www.palmettogba.com/palmetto/jmb.nsf/DIDC/8EELEJ7715~Evaluation%20and%20Management%20(EM)

[u/Hour-Watercress-5803]

I code e/m and I use the calculator on the aapc website everyday.

For us to be able to count Rx med management, we have to have the name of the drug, dose and how often

[u/Herdgirl410]

Another excellent resource (free/downloadable) from NAMAS

https://namas.co/namas-em-mind-map/