E&M Coding Grids: Are You Aware of Recent Changes?

Many health care professionals use E&M coding grids to assist with the application of E&M codes. In it’s Evaluation and Management Services Guide, CMS indicates that for determining the complexity of medical decision making, “The number of possible diagnoses and/or the number of management options that must be considered is based on:

• The number and types of problems addressed during the encounter;
• The complexity of establishing a diagnosis; and
• The management decisions that are made by the physician.

In general, decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem. The number and type of diagnosed tests performed may be an indicator of the number of possible diagnoses. Problems that are improving or resolving are less complex than those problems that are worsening or failing to change as expected. Another indicator of the complexity of diagnostic or management problems is the need to seek advice from other health care professionals.” 

This appears to be saying that if a patient comes to the emergency room with shortness of breath and the ER physician performs a chest x-ray, all the relevant and appropriate diagnostic studies, and establishes the diagnosis of pneumonia that he/she has made the diagnosis. Since the hospital participates in the quality initiative program and the appropriate treatment measures were initiated, only the ER physician gets credit for the “new problem.”  So, according to CMS, the attending physician, as party of his/her medical decision making, comments on the status of the pneumonia (E.g. stable, improved or worsening).  To view the CMS E&M Guide http://www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp. 

Are you following this approach to evaluating E&M codes?

Written by:  Georgeann Edford, RN, MBA, CCS-P, CPC, President of Coding Compliance Solutions, LLC and member of the CCH & MediRegs Coding Advisory Board.