Simplify E/M documentation and coding in your private practice

Andis Robeznieks , Senior News Writer

Often called the “language of medicine,” the Current Procedural Terminology (CPT®) code set is always evolving, and one reason for that evolution is to lower the administrative burden for physicians and their practices. 

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Services involved in the evaluation and management (E/M) of a patient’s health are covered by CPT codes 99202–99499. These services were also the subject of a massive effort by the AMA, the Centers for Medicare & Medicaid Services (CMS) and a coalition of 170 state and specialty medical societies to simplify coding and documentation requirements and make them more clinically relevant.

Private Practice Simple Solutions: E/M Documentation Burden Reduction,” an AMA STEPS Forward® Innovation Academy webcast, provides a review and explanation of these changes.

The webcast is part of the AMA Private Practice Simple Solutions series of free, open-access rapid-learning cycles that provide opportunities to implement meaningful changes that can immediately increase efficiency in private practices.

The webcast also uses the “AMA STEPS Forward Simplified Outpatient Documentation and Coding Toolkit” as a guide. The toolkit:

  • Describes the most recent billing and coding documentation guidelines.
  • Advises on how to implement workflow solutions for more efficient documentation.
  • Provides examples of documentation to help educate physicians and their teams.

Private practice physicians are able to access pre-recorded content presented by subject-matter experts at their convenience. The complete collection of AMA STEPS Forward® Innovation Academy webcasts are available on demand.

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The toolkit uses clinical vignettes (PDF) to help explain E/M CPT codes and concepts.

One vignette gives the example of a 60-year-old male with hypertension and hyperlipidemia who has come in for a medication review. The patient reports being well with no complaints.

An examination reveals normal BP, regular heart rate and rhythm, and clear lungs. The physician decides to continue current medications and treatment.

The vignette notes that the correct code for the encounter is 99214 based on meeting Level 4 criteria for diagnosis and risk and because it includes two of three medical decision-making (MDM) elements needed to meet the threshold for moderate or Level 4 MDM.

This is based on diagnosing at least two stable chronic conditions, straightforward interpretation of minimally complex data, and medication management with moderate risk of morbidity.

Another vignette tells of a 40-year-old single mother of two children with diet-controlled diabetes and obesity who recently has moved to the state and lives with a cousin while looking for a full-time job. She has had trouble finding a neighborhood grocery store and is uncomfortable taking public transportation and, because of out-of-pocket expense concerns, asked to defer laboratory testing until her next visit.

The physician discussed transfer of records from the patient’s former primary care physician and counseled on diet and exercise, but there is concern that social determinants of health—food insecurity and lack of income—may affect her care. Consultation with a social worker is planned to connect the patient with community resources and social support.

The vignette notes that the correct code for the encounter is 99204, meaning it is an outpatient visit with a new patient with a moderate level of MDM. This is based on diagnosis of two stable, chronic conditions, straightforward interpretation of minimally complex data, and moderate risk of morbidity—though diagnosis or treatment is significantly limited by social determinants of health.

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In addition to the MDM level, coding can be based on total time providing care for a patient on the date of service. This includes time spent before and after the visit, not just face-to-face time.

Other vignettes describe coding for a pediatric progress note and elements of Level 5 visits based on MDM and time.

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The toolkit also offers instruction on implementing team documentation workflows and training medical assistants or other non‑clinical staff to participate in team documentation as an additional key to increasing documentation efficiency.

“These changes enable physicians to give more of their undivided attention to patients while decreasing their after-clinic charting time,” the toolkit says.

Subscribe to the AMA’s CPT News email newsletter and to CPT Assistant Online, which provides information on the latest codes and trends in the medicine, clinical scenarios that demystify codes, information for training staff, appealing insurance denials and validating coding to auditors, and answering day-to-day coding questions.

Learn about the AMA Private Practice Physicians Section, which works to preserve the freedom, independence and integrity of private practice.