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Evaluation & Management Coding
Physician vs. Hospital
HP3
A part of Navigant Consulting
MdHIMA Annual Meeting
Baltimore Convention Center; Baltimore, Maryland
June 5, 2008

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Table of Contents
Section 1 » Definition and Uses
Section 2 » Physician E/M Services
Section 3 » Hospital E/M Services
Section 4 » Physician and Hospital E/M Comparison
Section 5 » Questions?
Section 6 » About Your Speaker & NCI

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Definition and Uses
Section 1

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What are Evaluation and Management Services?
» A category of billing for physician and facility services that focuses on
understanding the patient's problems and arranging a care plan to help.
» Evaluation and Management Services most often include
› Emergency Room Visits
› Inpatient Consultations
› Outpatient Clinic Visits
» Most often referred to as E/M services.

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Physician E/M Services
Section 2

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Physician E/M Component Overview
» To determine the appropriate level of service for a patient’s visit, it is
necessary to first determine whether the patient is new or already
established.
» The physician then uses the presenting illness as a guiding factor and his
clinical judgment about the patient’s condition to determine the extent of
key elements of service to be performed.
» The key elements of service are:
› History;
› Examination; and
› Medical Decision Making.
» The three key components appear in the AMA descriptors for office and
other outpatient services, hospital observation services, hospital inpatient
services, consultations, emergency department services, nursing facility
services, domiciliary care services, and home services.
» EXCEPTION: in visits which consist predominately of counseling or
coordination of care, the time spent is key in determining the level of E/M.
CMS Evaluation and Management Services Guide – March 2006

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Physician Key Component - History
» Documentation of patient history includes some or all of the following
elements:
› Chief Complaint (CC)
› History of Present Illness (HPI)
› Review of Systems (ROS)
› Past, Family, And/Or Social History (PFSH)
» The elements documented will determine the level of history for the E/M
level.

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Physician Key Component - Examination
» There are two types of examinations that can be performed during a
patient’s visit:
› General multi-system examination
› Single organ system examination
» Below are the body areas and organ systems that are recognized according
to the Current Procedural Terminology (CPT) book:

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Physician Key Component - Examination
» The elements documented will determine the level of examination for the
E/M level.

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Physician Key Component – Medical Decision Making
» Medical decision making refers to the complexity of establishing a
diagnosis and/or selecting a management option, which is determined by
considering the following factors:
› Number of possible diagnoses and/or management options;
› Amount and/or complexity of medical records, diagnostic tests, and/or other
information that must be obtained, reviewed and analyzed; and
› Risk of significant complications, morbidity, and/or mortality as well as
comorbidities associated with the patient's presenting problem(s), the diagnostic
procedure(s), and/or the possible management options.

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Physician Key Component – Medical Decision Making
» To qualify for a given type of medical decision making, two of the three
elements must either be met or exceeded.

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Hospital E/M Services
Section 3

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Hospital E/M Overview
» Separate CPT/HCPCS codes have yet to be established to describe E/M
services provided within a facility.
» Hospitals are permitted to utilize “physician” E/M to capture charges for
services provided.
› Physicians – expertise
› Hospitals – overhead
» To determine the appropriate level of service for a patient’s visit, it is
necessary to first determine whether the patient is new or already
established.
» Hospitals are to create their own system for determining visit level.
› In Maryland this has been established by the HSCRC.
› Outside of Maryland, various methods are utilized
‒ Point systems
‒ Time-Based
‒ Severity-Based
» It is not an expectation of payers that levels reported by the physician and
facility for the same patient, same encounter will be at the same level.

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Hospital E/M – Maryland HSCRC
» Emergency Department Visits
› Clinical Care Time (CCT)
‒ Level I 0-<15 minutes
‒ Level II 15-<30 minutes
‒ Level III 30<60 minutes
‒ Level IV 60<120 minutes
‒ Level V 120+ minutes
› Includes all procedures and services performed by ED staff
» Outpatient Clinic Visits
› Clinical Care Time (CCT)
‒ Level I 0-10 minutes
‒ Level II 11-25 minutes
‒ Level III 26-45 minutes
‒ Level IV 46-90 minutes
‒ Level V 91+ minutes
› Procedures can be reported separately

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Physician and Hospital
E/M Comparison
Section 4

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New vs. Established Patient
» E/M codes will often differ between new and established patients.
» Criteria differs between physician and hospital reporting of E/M services.
› Physician
‒ New vs. Established
◦ Pertains to whether a patient has been seen by a provider or a fellow provider from
the same specialty of the same group practice within the past 3 years
› Hospital
‒ New vs. Established
◦ Pertains to whether or not the patient already has a medical record number
◦ If patient had use of that medical record number within the past 3 years, the patient
is considered an established patient to the hospital
◦ The same patient could be “new” to a physician or department, but “established” to
the hospital

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Level Determination
» Physician
› Level determination for physicians can be complex.
› Subject to great scrutiny.
» Hospital
› Level determination for hospitals remains to be unstructured.
› Not easily scrutinized.

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Reportable CPT/HCPCS
» E/M Services do not always share the same CPT/HCPCS when reporting
services performed by a physician or on behalf of a facility.

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Section 5

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About Your Speaker &
Navigant Consulting
Section 6

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Speaker
Caroline Rader, MBA, MSHCA, CHC
» Associate Director, Coding/Documentation
» Baltimore, Maryland
» Experience
› 10+ years of billing compliance, charge description master and
revenue cycle experience
‒ Industry and Consulting
‒ Maryland HSCRC and APC
» Contact Information:
› Email: caroline.rader@navigantconsulting.com
› Phone: 410-463-9867
› Fax: 866-861-0084

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NCI Healthcare
Provider Practice Group
» Our comprehensive services to healthcare providers include:
› Performance improvement
› Strategic advisory
› Revenue performance improvement
› Financial advisory
› Supply chain management
› Interim management

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Our Values
Responsive – we anticipate and respond quickly to client needs. We are experts in
highly regulated environments, and our deep industry knowledge enables us to
develop innovative and practical solutions to our clients’ business challenges.
Resourceful – as an integrated company, we are able to leverage the diverse skills and
industry expertise of our professionals to help clients overcome the challenges of
uncertainty, risk, distress and significant change. We work seamlessly, drawing from
an array of resources, to help clients transform ideas in actions.
Trustworthy – clients count on us for effective solutions, accurate answers and honest
responses. We approach every task in a straightforward manner, providing
independent and objective advice in which clients can have confidence.
Innovative – we have a history of helping clients identify and implement innovative
solutions to complex and challenging business issues. Our entrepreneurial culture
encourages all professionals to be innovative exploring new ideas and methods to help
clients address their business challenges.

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Our Unique Approach
» Integration – We believe it is imperative to integrate a strategic and
operational focus. Linkages to financial and clinical performance are
critical.
» Experience – Our consultants have on average 10+ years of operational
and/or consulting experience. Our senior resources work on the project –
not just lead the project.
» Flexibility – We are a consulting group consisting of highly experienced
consultants. We bring methodology but tailor efforts to meet the clients
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» Size – We are not too big…not too small. With over 300 employees serving
the healthcare industry, we can leverage our operational, clinical, financial,
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We believe there are key differentiators that drive Navigant Consulting’s
unique approach to assisting our clients.