The Woes of E/M Evolution
By Lisa Boyer, RHIT, CPMA
Out with the 95/97 Evaluation and Management (E/M) guidelines, in with the new and improved 2023 E/M guidelines - Sounds easy right!? While the intent to reduce provider documentation burden may have been accomplished, the learning curve for providers and coders is real! Don’t get me wrong, there are several advantages to the updated guidelines; however, there are still rules that seem more difficult to follow than they should be. Not to mention breaking out of habits developed since 1995! While there are a couple of new E/M guidelines that have me scratching my head, today I would like to cover the confusion of how and when to count the review and analysis of tests.
I am an E/M coding nut and really enjoy this topic, so not only do I provide E/M education, I attend as many educational sessions as possible because there are many experts on this topic. At pretty much every webinar I have attended regarding the updated guidelines, proper counting of tests has come up as a challenge. Not only do coders need to understand it, but we also have to explain to the providers why they often cannot count reviewing a test as part of their medical decision making (MDM), even though it is a crucial part of the patient’s care.
Under the definition of amount and/or complexity of data to be reviewed and analyzed; … ”Ordering a test is included in the category of test result(s) and the review of the test result is part of the encounter and not a subsequent encounter.” Here is what I have come to understand… You can get “one point” per unique test ordered and/or reviewed during an encounter. (Example: CMP, Xray = 2 points under Column 2 in MDM grid). Other examples of questions that have come up are listed below.
A couple of common questions go something like this:
Does each new provider count review of lab results for tests they did not order?
If new provider is in the SAME specialty, subspecialty or group practice: CANNOT count results reviewed during a subsequent visit
If the new provider is in a DIFFERENT specialty, subspecialty or group practice: Yes, CAN count results reviewed during a subsequent visit (Ex: Primary care ordered a test in the office and refers the patient to an endocrinologist for f/up. Both the primary care provider and the endocrinologist would be able to count the lab results)
Do LAB tests reviewed count on a subsequent inpatient visit if they were ordered the day before by a provider in the same group/specialty?
No, if the same group/specialty – you only get credit one time for ordering/reviewing the test and that is typically when it is ordered. However, your facility can identify a process on when to capture the “credit” for the test (upon ordering or reviewing)
Example: When the test is ordered on 2/1 and the result comes in on 2/2
It boils down to whether subsequent providers reviewing results are in the same specialty/subspecialty/group. Basically, you can only count a test as ordered/reviewed one time per specialty/subspecialty/group. It is important to develop a robust internal coding procedure to ensure your coding team performs processes consistently and has a thorough understanding of the updated E/M guidelines.
Elevate Medical Solutions offers handy reference booklets that were created to assist coders and providers in easily referencing E/M helpful tips. The booklets are easy to use and do not simply copy and paste the rules and descriptions. Tips on selecting E/M codes (MDM vs time), prolonged services and documentation abound in this 5x5 booklet that can fit in provider coat pockets. Download your copy here.
