How To Use the Evaluation & Management
(E&M) Codes Properly

Part 3:   Mastering the E/M Guidelines

This section was compiled by Frank M. Painter, D.C.
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FROM:   Chiropractic Economics

By Kathy Mills Chang, MCS-P

   Jump to:
   Part 1:   The 3 Key Components of the E/M Guidelines   or
   Part 2:   A Closer Look at E/M Guidelines   

The medical decision making component ties it all together.

Welcome to part three this focus series on the evaluation and management (E/M) guidelines. This will wrap up what you need to know to stay compliant with E/M coding for the Centers for Medicare and Medicaid Services (CMS).

In the last installment, the elements of your patientís examination were reviewed and you learned how it is the second of the three key elements of the patientís E/M service. Now, the third part of this E/M documentation series will unravel the final component of the E/M code: medical decision making (MDM). For chiropractors, this is usually the diagnosis and treatment plan.

Three key components of the E/M guidelines:

1.   Patient history
2.   Examination
3.   Medical Decision Making (MDM

Remember that your patientís medical record should establish a chronological record of exams, tests and results, and treatments and treatment plans (including the diagnosis and prognosis of the illness or disease). The medical record should corroborate the reimbursement request and is requisitioned by most payers for adjudication of claims when reimbursement is in question.

Your medical recordkeeping is a vital piece in the puzzle of reimbursement. Therefore, a clear understanding of all requirements, including those of MDM is critical.

MDM is fraught with controversy and confusion, and it is the most difficult of the three components of E/M coding.

Three subcomponents of MDM that must be considered:

1.   The number of diagnoses and/or management options that must be documented in the patient record.
2.   The amount of data that is to be reviewed.
3.   The risk of complications, morbidity, and/or mortality.

MDM should reflect your cognitive work, clinical skill, and judgment in rating the complexity of the decision- making process as well as the complexity of the diagnosis and therapeutic options. More than the other parts of E/M (the history and exam), it will likely be the MDM component that determines the level of E/M service you are able to bill, especially for a new patient.

Because MDM can be conceptually challenging, there are some doctors who simply guess at the medical decision-making levels (it certainly doesnít help that the MDM guidelines leave much unstated and not clearly understood). According to the Office of Inspector General (OIG) and CMS, chiropractors seem to consistently lag behind other professions when it comes to proper coding and documentation.

Moreover, there are numerous doctors who consistently under-code their levels of E/M service, mistakenly believing that this allows them to fly under the radar of auditors. It is important to know that under-coding is as bad as over-coding claims, and is in direct violation of the False Claims Act (when done purposely). In addition, there are fines and penalties that can be imposed on any person who knowingly submits a false claim for payment.

As a general rule, each increase of one E/M level (e.g., increasing from 99201 to 99202) increases the usual and customary fee for the code by about 50 percent. Some doctors think of their medical decision making as ďroutineĒ and select a straightforward MDM.

If you are meeting the documentation requirements for billing higher level E/M codes, and are doing the work, you have every right to be paid for it. But your documentation must reflect the correct elements of MDM to justify the code.

On the flip side, doctors tend to believe they can justify a higher level MDM code because the patient they are seeing is in severe pain or experiencing many symptoms. This isnít necessarily how it works.

Take a look at the following two patients (and unfortunately common examples) to make a simple determination.

Example one:   An older woman presents to you for the first time, experiencing severe pain in her neck and right shoulder. She is currently being treated with another physician for breast cancer and is on chemotherapy. She has been unable to turn her head to the right more than 15 degrees. She has no previous history of this condition.

Example two:   An older man reports to you for the first time, experiencing discomfort in his lower back and legs. He is currently under treatment with his family physician for COPD, hypertension, hypertrophic arthritis, and diabetes. His forward flexion is restricted, and all his movements are slow and guarded. He has no previous history of this condition.

Based on these two patients who both suffer from underlying conditions, which one do you think might qualify for a higher level of MDM? Even though our first patient is suffering from a disease that may be terminal, it does not necessarily qualify for billing a higher level of E/M based on decision making.

Actually, our second patient has numerous health problems and there would likely be much more data to be reviewed. For this reason, it would in all probability be the second case that would warrant a higher level of MDM.

Both the 1995 and 1997 E/M guidelines are the same for MDM.

MDM is based on the complexity of the decision in making an accurate diagnosis and in establishing a treatment plan for the patient. The complexity of that decision is broken down and divided into three subcomponents:

1.   The number of diagnoses or management options. These can be minimal, limited, multiple, or extensive. They are scored according to whether the problem is self limited, established, or new, and whether the condition is stable, improved, or worsening. These can also be affected if you plan any additional work up. You must document in the patient record the number of diagnoses and management options based on the number of conditions or problems you are addressing during the encounter.

2.   The amount of data to be reviewed. This can be none, minimal, limited, moderate, or extensive. It can include any labs ordered or reviewed, X-rays ordered or reviewed, medical procedures ordered or reviewed, discussion of test results with the performing physician, a decision to obtain old records, and independent visualization of images, tracings, or specimens.

3.   The risk of complication or death if the condition should go untreated. Risk can be minimal, low, moderate, or high. This can include reviewing problems from minor to chronic, acute and uncomplicated, to new problems and exacerbations that range from minor to severe.

According to the documentation guidelines outlined in the current procedural terminology (CPT), there are four levels of MDM that are recognized:

1.   Straightforward decision making:   Minimal diagnosis and treatment. There is minimal or no complexity of data to be reviewed and minimal risk to the patient.

2.   Low-complexity decision making:   Limited number of diagnosis and management options, limited data to be reviewed, and low risk of complications.

3.   Moderate-complexity decision making:   Multiple diagnosis and management options, moderate amount and complexity of data to review, and a moderate risk to the patient of complications or death if left untreated.

4.   High-complexity decision making:   Extensive number of diagnosis and management options, extensive amount and complexity of data to be reviewed, and a high risk to the patient of complications or death if left untreated.

Because the clinical examples on the MDM score sheets reference medicine (i.e., biopsies, drugs, and IVs), it can sometimes be more difficult to quantify risk based on those examples since they donít apply to chiropractic care and treatment. Regardless, you must utilize the industry standard of MDM, as it would be those same score sheets and point systems an auditor would use to evaluate your MDM and level of E/M service billed.

Now that all three key components of E/M coding have been covered, you have all the tools necessary to properly code evaluation and management services for your patients. By using appropriate judgment and clinical recordkeeping, you can display the corporate integrity that proclaims your desire to curb fraud, abuse, and waste, and set a great example for your colleagues that sets you apart from the pack.

Kathy Mills Chang is the founder of her own consulting firm assisting doctors with finding financial and reimbursement ease in practice. She also serves as Foot Levelersí insurance adviser and can be reached at 888-659-8777 or



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