A case-based approach to outpatient evaluation and management service coding

Understanding Center for Medicare and Medicaid Services (CMS) documentation and coding rules is challenging for most physicians. To accurately bill for clinical services, physicians must learn a system that may initially seem daunting, but is in fact governed by a small number of straightforward rules. The Evaluation and Management (E/M) guidelines for all service codes specify 3 components: history, examination, and medical decision-making, each with a defined set of elements or characteristics. Service coding is based on the level of care supported by the number of history and examination elements and the complexity of decision-making. This article will clarify the guidelines for outpatient clinical services and suggest a practical method of selecting appropriate E/M codes. Because physicians must often choose between billing codes 99213 and 99214 for a visit by an established patient, it will particularly focus on the minimum documentation needed to bill a 99214 code.