Coding Challenges for Inpatient Evaluation and Management Services

Evaluation and Management codes, often known as E&M codes, refer to a special medical coding scheme that involves the use of CPT codes ranging from 99202 to 99499 to reflect services rendered by a physician or other qualified healthcare practitioner.

When a provider is involved in evaluating or managing a patient’s health, CPT codes for assessment and management are used. Specialty care consultants, emergency room physicians, and general care physicians frequently use these E&M CPT codes.

E&M codes include, for example, office visits, hospital visits, home services, and preventive medicine services. Evaluation and management services do not include operations such as surgeries, radiography and diagnostic testing, and certain treatment regimens.

E&M Codes for Inpatient Care

For Initial hospital treatment, E&M codes (99221, 99222, and 99223) are used to document the patient’s initial hospital inpatient interaction with the admitting physician. For additional inpatient care, E&M codes (99231, 99232, 99233) are used to indicate additional hospital visits.

On the other hand, E&M codes (99238, 99239) are used to report the work performed to discharge a patient from an inpatient stay. When it comes to Admission and Discharge on the same day, E&M codes (99234 – 99236) are used to report services for a patient who is admitted and discharged on the same calendar day from an observation or inpatient stay. To bill these codes, the patient must stay for at least eight hours.

Challenges to Inpatient E&M Medical Coding

Evaluation and Management medical coding for inpatient care involves a number of challenges that leads to obstruction of outcomes. Firstly, because there are multiple criteria, the rules are quite complex. As a result, comprehensive chart documentation is substantial, and the selection process requires a high degree of clinical judgement.

Also, finding an acceptable E/M code is significantly more difficult than selecting an eye code. Experts regularly dispute over the proper code to use in a given situation. Professionals in these disciplines choose eye codes twice as often as E/M codes, according to the Centers for Medicare & Medicaid Services’ 2013 Part B Extract Summary System Data for Ophthalmology and Optometry.

Unfortunately, not all experiences are appropriately described by eye codes. Some visits need the use of E/M coding criteria, which are more formal and severe than eye codes.

The E/M rules haven’t been updated since 1997, and there are faults. The code selection procedure, in particular, counts aspects from the patient’s history, examination, and medical decision-making to establish the level of service without seriously considering the entries’ use, especially when the patient’s previous visit was relatively recent (i.e., 1 day, or 1 week). Such issues have been amplified by EHRs.

Medical Coding Best Practices for Inpatient Evaluation and Management

More is not necessarily better when it comes to medical coding for inpatient evaluation and management services. Medical records that are detailed and accurate are the finest. An accurate note reflects the treatment given for the patient’s condition.

Notes that aren’t needed have little or no value. Inadequately trained technicians and scribes can generate unnecessary notes, resulting in inefficiency. A thorough history and examination are not required for every patient contact. When copying old information into a current record, exercise caution.

The severity of the condition and treatment alternatives are important factors in deciding the quality of service when choosing an E/M code. Clinicians should constantly consider medical decision-making when selecting the level of care, as this will ensure proper E/M code selection even if the patient’s history and examination are bloated within the EHR.

Medical coding jobs are considered one of the emerging trends in value-based healthcare services today. Learn about medical coding, its challenges and best practices to secure the best opportunities in the field.

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