{"id":531,"date":"2024-06-18T17:33:26","date_gmt":"2024-06-18T17:33:26","guid":{"rendered":"https:\/\/zenmedinc.com\/blog\/uncategorized\/how-to-improve-venenatis-ultrices-nulla\/"},"modified":"2024-08-27T05:36:31","modified_gmt":"2024-08-27T05:36:31","slug":"evaluation-and-management-coding","status":"publish","type":"post","link":"https:\/\/zenmedinc.com\/blog\/evaluation-and-management-coding\/","title":{"rendered":"Three Years Later: Where Is Your Evaluation and Management Coding. From 2021 \u2013 2024, What Have We Learned?"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-post\" data-elementor-id=\"531\" class=\"elementor elementor-531\">\n\t\t\t\t<div class=\"elementor-element elementor-element-2de4ab7e e-flex e-con-boxed wpr-particle-no wpr-jarallax-no wpr-parallax-no wpr-sticky-section-no e-con e-parent\" data-id=\"2de4ab7e\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-3b0e9344 elementor-widget elementor-widget-text-editor\" data-id=\"3b0e9344\" data-element_type=\"widget\" data-widget_type=\"text-editor.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t\t\t<p><style>\nspan.highlight\n{\nbackground-color:yellow;\n}\n<\/style><\/p>\n<p><span style=\"color: #000000;\"><\/span><\/p>\n<h3 align=\"center\"><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>From 2021 &#8211; 2024, What Have We Learned?<\/b><\/span><\/span><\/h3>\n<p><span style=\"color: #000000;\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">It seems a lifetime ago, but it\u2019s only been three years, since CMS, The AMA and CPT, made the first overhaul of the traditional 1995\/1997, Evaluation and Management Guidelines, in what was supposed to be a new and easily understood mode of documenting Provider visits with their Patients. This first venture in change proved to need some further tweaking, so it was overhauled again in 2023 to some degree, to try to ease some of the circling questions about the now infamous MDM Grid, that we\u2019ve all come to know<\/span><\/span><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\"><b>. <\/b><\/span><\/span><\/span><\/p>\n<p><span style=\"color: #000000;\"><\/span><\/p>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">With that, comes guidance from CMS, who issued the following last August in their updated 2023 MLN Evaluation and Services Guide, on page 15:<\/span><\/span><\/p>\n<p><span style=\"color: #000000;\"><\/span><\/p>\n<p class=\"is-layout-flow wp-block-quote-is-layout-flow\"><span style=\"color: #000000;\">\u201c<span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\"><b>General principles of medical record documentation apply to all medical and surgical services and settings. While E\/M services vary, like the nature and amount of physician work needed, these general principles help make sure medical record documentation is correct for all E\/M services\u201d <\/b><\/span><\/span><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">(see link below)<\/span><\/span><\/span><\/p>\n<ol>\n<li>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"> <span class=\"highlight\"><i>The medical record should be complete and legible<\/i><\/span><\/span><\/span><\/p>\n<\/li>\n<li>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><i>Your documentation of each patient encounter should include:<\/i><\/span><\/span><\/p>\n<\/li>\n<li>\n<p><span style=\"color: #000000;\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\"><i><span class=\"highlight\">Reason for the encounter and relevant history, physical examination findings and prior diagnostic test results <\/span><\/i><\/span><\/span><\/span><\/p>\n<\/li>\n<li>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><i><b><span class=\"highlight\">Assessment, clinical impression, or diagnosis <\/span><\/b><\/i><\/span><\/span><\/p>\n<\/li>\n<li>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><i><b><span class=\"highlight\">Medical plan of care<\/span><\/b><\/i><\/span><\/span><\/p>\n<\/li>\n<li>\n<p><span style=\"color: #000000;\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\"> <i><span class=\"highlight\">If you don\u2019t document the date, legible name of the observer and your rationale for ordering diagnostic and other services, it should be easily inferred<\/span><\/i><\/span><\/span><i> <\/i><\/span><\/p>\n<\/li>\n<li>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><i>Past and present diagnoses should be accessible to you or the consulting physician <\/i><\/span><\/span><\/p>\n<\/li>\n<li>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><i>You should identify appropriate health risk factors <\/i><\/span><\/span><\/p>\n<\/li>\n<li>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><i>You should document the patient\u2019s progress, response to and changes in treatment, and revision of diagnosis <\/i><\/span><\/span><\/p>\n<\/li>\n<li>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><i>Your claim correctly shows your services <\/i><\/span><\/span><\/p>\n<\/li>\n<li>\n<p><span style=\"color: #000000;\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\"><i><span class=\"highlight\">The medical record documentation supports the level of service you report to a payer<\/span><\/i><\/span><\/span><i> <\/i><\/span><\/p>\n<\/li>\n<li>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><i><span class=\"highlight\">Documentation in the medical record should report the diagnosis and treatment codes you report on the health insurance claim form or billing statement <\/span><\/i><\/span><\/span><\/p>\n<\/li>\n<li>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><i><b><span class=\"highlight\">Don\u2019t use the volume of documentation to decide the specific level of service to bill<\/span><\/b><\/i><\/span><\/span><\/p>\n<\/li>\n<li>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><i><span class=\"highlight\">Document services during the encounter or as soon as possible after the encounter to keep the medical record accurate.<\/span><\/i><\/span><\/span><\/p>\n<\/li>\n<\/ol>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">As you can see, I highlighted several areas of the updated Guidance, as those seem to be the ongoing areas of focus with various providers I have worked with. Those areas, 1, 3, 4, 5, 6, 11, 12, 13 and 14, to me, are mission critical areas in the telling of the story of what took place during that encounter. <\/span><\/span><\/p>\n<p><span style=\"color: #000000;\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">For the sake of this blog, I want to focus on number 4, 5 and 13, with respect to the changes in MDM for both 2021 and 2023\/2024 Guidelines. Many providers ask about what qualifies for a Level 4 E&amp;M service and it really is much simpler to get to if you understand what the MDM Grid is telling you to document during a visit. If we look at the MDM Grid below in Pic 1, we see that Level 4 <\/span><\/span><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\"><i>(either 99214 or 99204 \u2013 there is no difference in the levels anymore),<\/i><\/span><\/span><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\"> can be met with proper documentation in at least two of the three columns on the 2024 E&amp;M Coding Tool\/MDM Grid, pasted below (source- pcc.com \u2013 see below for link).<\/span><\/span><\/span><\/p>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">If we look at Column 1, which starts with Number and Complexity of Problems Addressed, we see that there are five bullets points, for indicating and documenting the Chief Complaint and combining it with diagnoses and existing comorbidities, for evaluation for further testing and\/or treatment, if any, is the first step in determining if the visit will support the both the Problems Addressed and a Moderate Level of Complexity. <\/span><\/span><\/p>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">Let\u2019s turn our attention to Column 2, we see that it starts with the Amount and\/or Complexity of Data, to include, each unique test, order or document, which contributes to a combination of 2 for Level 3, or 3 for a Level 4, in Category 1 (the first of 3 named), below. So, if we look at Level 4 \u2013 it says, \u201cone category required\u201d, which means that all indicated dated in each of the 3 categories under Level 4, must be met.<\/span><\/span><\/p>\n<p><span style=\"color: #000000;\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">That means that you only need to meet 1 Category under Level 4, but you must <\/span><\/span><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\"><b>meet each item indicated<\/b><\/span><\/span><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\"> under either Category 1, which has 4 bullet points, Category 2, which has 1 bullet point or Category 3, which also has 1 bullet point. <\/span><\/span><\/span><\/p>\n<p><span style=\"color: #000000;\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">For example, a Unique test is defined by the CPT code set. When multiple results of the same unique test (e.g., serial blood glucose values) are compared during an E\/M service, <\/span><\/span><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\"><b>count it as one unique test<\/b><\/span><\/span><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\">.<\/span><\/span><\/span><\/p>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">As we cross the finish line with Column 3, we can see that it is all about Risk, which includes Morbidity from Additional Diagnostic Testing and\/or Treatment. There are 4 bullet points under the Risk category in column 3, with either Prescription drug management, decision for minor or major surgery or indications for social determinants of health (Examples may include food, safety, welfare, unemployment, lack of education and housing insecurity). <\/span><\/span><\/p>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\">Qualified providers apply common meanings to define risk, such as \u2018high\u2019, \u2018medium\u2019, \u2018low\u2019, or \u2018minimal\u2019 and these do not require the provider to quantify these definitions. To accurately calculate medical decision making, the level of risk is used to assess potential outcomes, positive or negative, based on the problem(s) addressed during the encounter, depending on the plan of care (POC). Risk always includes Medical Decision Making, (MDM), in relation to ordering further testing\/treatment or hospitalization or waiving it entirely. A patient\u2019s risk and the criteria in which a provider potentially manages it, is part of overall MDM and is reported by the provider as part of the encounter that day. <\/span><\/span><\/p>\n<p><img fetchpriority=\"high\" decoding=\"async\" class=\"alignleft wp-image-1547 size-full\" src=\"https:\/\/zenmedinc.com\/blog\/wp-content\/uploads\/2024\/07\/coding-tool.jpg\" alt=\"E&amp;M Coding Tool\" width=\"784\" height=\"186\" srcset=\"https:\/\/zenmedinc.com\/blog\/wp-content\/uploads\/2024\/07\/coding-tool.jpg 784w, https:\/\/zenmedinc.com\/blog\/wp-content\/uploads\/2024\/07\/coding-tool-300x71.jpg 300w, https:\/\/zenmedinc.com\/blog\/wp-content\/uploads\/2024\/07\/coding-tool-768x182.jpg 768w\" sizes=\"(max-width: 784px) 100vw, 784px\" \/><\/p>\n<p>\u00a0<\/p>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>TIPS TO REMEMBER:<\/b><\/span><\/span><\/p>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>MDM includes establishing diagnoses, assessing the status of a condition, and\/or selecting a management option.<\/b><\/span><\/span><\/p>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>MDM is defined by three elements: <\/b><\/span><\/span><\/p>\n<ol>\n<li>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><i>The number and complexity of problem(s) that are addressed during the encounter<\/i><\/span><\/span><\/p>\n<\/li>\n<li>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><i>The amount and\/or complexity of data to be reviewed and analyzed<\/i><\/span><\/span><\/p>\n<\/li>\n<li>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><i>The risk of complications and\/or morbidity or mortality of patient management<\/i><\/span><\/span><\/p>\n<\/li>\n<\/ol>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>Happy Coding!<\/b><\/span><\/span><\/p>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>References:<\/b><\/span><\/span><\/p>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>PCC.COM E&amp;M LEVELING TOOL: <\/b><\/span><\/span><span style=\"color: #0000ff;\"><u><a style=\"color: #0000ff;\" href=\"https:\/\/learn.pcc.com\/help\/chart-code-and-bill-for-em-office-visits\/#PCC8217s_E038M_Coding_Tool\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\"><b>https:\/\/learn.pcc.com\/help\/chart-code-and-bill-for-em-office-visits\/#PCC8217s_E038M_Coding_Tool<\/b><\/span><\/span><\/a><\/u><\/span><\/p>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>CMS MLN 2023 E&amp;M SERVICES GUIDE: <\/b><\/span><\/span><span style=\"color: #467886;\"><u><a href=\"https:\/\/www.cms.gov\/outreach-and-education\/medicare-learning-network-mln\/mlnproducts\/downloads\/eval-mgmt-serv-guide-icn006764.pdf\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\"><b><span style=\"color: #0000ff;\">https:\/\/www.cms.gov\/outreach-and-education\/medicare-learning-network-mln\/mlnproducts\/downloads\/eval-mgmt-serv-guide-icn006764.pdf<\/span><\/b><\/span><\/span><\/a><\/u><\/span><\/p>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>AMA 2023 E&amp;M:<\/b><\/span><\/span> <span style=\"color: #0000ff;\"><u><a style=\"color: #0000ff;\" href=\"https:\/\/www.ama-assn.org\/system\/files\/2023-e-m-descriptors-guidelines.pdf\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\"><b>https:\/\/www.ama-assn.org\/system\/files\/2023-e-m-descriptors-guidelines.pdf<\/b><\/span><\/span><\/a><\/u><\/span><\/p>\n<p><span style=\"font-family: Calibri, serif; color: #000000;\"><span style=\"font-size: small;\"><b>2023 AAPC AUDIT RESOURCES TOOL: <\/b><\/span><\/span><span style=\"color: #0000ff;\"><u><a style=\"color: #0000ff;\" href=\"https:\/\/www.aapc.com\/resources\/em-audit-tool-ebrief\"><span style=\"font-family: Calibri, serif;\"><span style=\"font-size: small;\"><b>https:\/\/www.aapc.com\/resources\/em-audit-tool-ebrief<\/b><\/span><\/span><\/a><\/u><\/span><\/p>\n<p><span style=\"color: #000000;\"><\/span><\/p>\t\t\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>From 2021 &#8211; 2024, What Have We Learned? It seems a lifetime ago, but it\u2019s only been three years, since CMS, The AMA and CPT, made the first overhaul of the traditional 1995\/1997, Evaluation and Management Guidelines, in what was supposed to be a new and easily understood mode of<\/p>\n","protected":false},"author":2,"featured_media":1779,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"default","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","theme-transparent-header-meta":"default","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"set","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[14],"tags":[38,39,20,30,31],"class_list":["post-531","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-coding","tag-em-coding","tag-em-documentation","tag-mdm","tag-medical-coding","tag-medical-record-documentation"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v25.5 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Three Years Later: Where Is Your Evaluation and Management Coding. From 2021 \u2013 2024, What Have We Learned? - ZenMed Solutions Inc<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/zenmedinc.com\/blog\/evaluation-and-management-coding\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Three Years Later: Where Is Your Evaluation and Management Coding. From 2021 \u2013 2024, What Have We Learned? - ZenMed Solutions Inc\" \/>\n<meta property=\"og:description\" content=\"From 2021 &#8211; 2024, What Have We Learned? 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