Understanding E&M codes and getting the latest updates

Understanding E&M codes and staying updated on relevant changes are an important part of modern healthcare. Using the correct codes is essential to minimizing billing errors and avoiding financial penalties and audits. A thorough understanding of E&M codes helps practices streamline billing processes and promote better patient outcomes through accurate recording of medical information.

E&M codes standardize the documentation and billing process for patient encounters. To help with precise reimbursement and quality evaluation, these codes classify visits according to their complexity and the resources used. They help healthcare providers receive the proper compensation and make it easier for professionals to communicate regarding patient care and treatment plans. Keep reading to gain a comprehensive understanding of E&M codes and to learn about the latest changes and updates.

In medical billing, E&M codes serve as the backbone of reimbursement processes, linking the services provided to the appropriate charges. They classify the level of service rendered during patient encounters so billing specialists can assign accurate fees and reimbursement. Proper documentation of E&M codes guarantees compliance with coding regulations and optimizes revenue cycle management for healthcare facilities.

Other types of coding are used in the healthcare industry to work with E&M codes, including: 

HCPCS codes, which are used to identify specific medical procedures, diagnostic tests, durable medical equipment, drugs, and other healthcare services provided during or in association with an E&M visit. For example, if a patient undergoes a specific diagnostic test or receives a particular medication during an office visit, the appropriate HCPCS code(s) would be reported alongside the corresponding E&M code to accurately document and bill for all services rendered.

When discussing E&M codes, a digit code refers to the numerical representation used to categorize and identify specific types of medical services within the code set. Each E&M code consists of a series of digits that convey information about the level of complexity and resources required for a patient encounter. The Current Procedural Terminology (CPT) code set includes codes for services other than E&M, including radiologic imaging and operations.

Procedure codes specify the services rendered during patient encounters. Diagnosis codes identify the patient's condition or reason for the visit. Together, procedure and diagnosis codes complement E&M codes by offering comprehensive documentation of the patient encounter, including the services performed and the medical reasons behind them.

The following groups are part of the E&M coding system:

Code modifiers ensure accuracy in coded claims by indicating unique aspects of patient encounters that might affect reimbursement or treatment decisions. Medical coding professionals use modifiers to distinguish between different levels of complexity or to denote special situations not fully captured by specific codes. For instance, modifier 25 is necessary when a significant E&M service is provided on the same day as another procedure. This ensures appropriate reimbursement and avoids denial of claims. Similarly, modifier 24 is used during the postoperative period to indicate an E&M service unrelated to the initial surgery. These modifiers help accurately bill and track revenue codes while complying with coding regulations and obtaining approval codes for reimbursement.

The International Classification of Diseases, 10th Revision (ICD-10) uses alphanumeric codes to categorize illnesses, injuries, and other health issues. ICD-10 codes help to document patient diagnoses and the reasons for encounters.

The proper assignment of ICD-10 codes alongside E&M codes is essential for accurate billing and reimbursement. ICD-10 codes also contribute to quality reporting initiatives by capturing data on patient diagnoses and outcomes associated with specific E&M services. This enhances performance evaluation and quality improvement efforts.

The transition from ICD-9 to ICD-10 in E&M coding brought significant changes to medical coding practices. ICD-10 offers more specificity with alphanumeric codes, allowing for detailed documentation of diagnoses in medical records compared to the numeric codes of ICD-9. This increased specificity enables healthcare providers to use specific care codes that accurately represent patient conditions. Additionally, ICD-10 provides alternative codes for greater precision while accommodating new diagnoses and procedures. Healthcare professionals must be careful to use valid ICD 9/10 CM codes to maintain compliance, accurately represent patient encounters, and obtain appropriate reimbursement.

A provider specialty code refers to a specific code that designates the medical specialty or area of practice of a healthcare provider. A primary care physician may use different E&M codes than a specialist, like a cardiologist or neurologist. Understanding the nuances of provider specialty codes helps professionals to accurately select the appropriate service codes that align with the care provided. Here are some examples of medical specialties and how they might use E&M codes for medical billing:

Geriatricians. May use higher-level E&M codes due to the complexity of managing multiple chronic conditions in elderly patients.

Medical code changes happen every year, and it can be overwhelming to keep track of what codes are new, revised, and deleted. Let's look at some important changes to evaluation and management (E&M) codes that took effect January 1, 2024, as well as several ICD-10-CM diagnosis code changes that became effective October 1, 2023. Our goal is to help you ensure clean claims, reduce denials, and promote revenue integrity in your medical practice.

In the 2024 CPT code update, you’ll find notable E&M-related changes for:

In total, the annual update to the CPT code set created 349 editorial changes, including 230 additions, 49 deletions, and 70 revisions. This includes the consolidation of more than 50 previous codes that streamline the reporting of immunizations for COVID-19.

The CPT Editorial Panel also approved the provisional codes (91318-91322) to identify monovalent vaccine products from Moderna and Pfizer for immunization against COVID-19.

Want to learn more about the changes? Take a look at this AMA press release and monitor the CMS website for an updated code list. You can also read this AMA article and definitely be sure to purchase a 2024 CPT Manual. 

The fiscal year (FY) 2024 ICD-10-CM code updates that took effect October 1, 2023 includes 395 code additions, 25 code deletions, and 13 code revisions. Here are some of the most notable changes:

A new ICD-10-CM diagnosis code for resistant hypertension (I1A.0) captures cases where a patient’s hypertension does not respond well to aggressive medical treatment. 

Four new codes for metabolic disorders replace ICD-10-CM diagnosis code E88.81 (metabolic syndrome): 

New ICD-10-CM diagnosis code for chronic migraine with aura (G43.E) provides additional specificity in terms of "intractable vs. not intractable" and "with or without status migrainosus." 

Four new, more specific ICD-10-CM diagnosis codes for Parkinson’s disease replace ICD-10-CM code G20 (Parkinson’s disease):

There’s also a new ICD-10-CM diagnosis code for unspecified Parkinsonism (G20.C). This is a general healthcare term for a group of neurological disorders causing movement problems similar to those seen in Parkinson’s disease (e.g., tremors, slow movement, and stiffness).

CPT no longer includes ICD-10-CM diagnosis code J15.6 (pneumonia due to other gram-negative bacteria). Instead, report 1 of these 2 new, more specific medical codes:

There’s a new ICD-10-CM diagnosis code for dense breasts, unspecified (R92.3). 

Be sure to put these 2 new ICD-10-CM diagnosis codes on your radar:

Similarly, make sure you’re aware of these 5 new ICD-10-CM diagnosis codes for conflicts children may have with relatives or guardians:

Finally, note that there are 2 new ICD-10-CM diagnosis codes for noncompliance due to financial hardship:

Consider these 3 strategies to ensure a compliant healthcare revenue cycle and promote revenue integrity in your medical practice:

Make sure coders understand the new codes and review the FY 2024 ICD-10-CM official guidelines for coding and reporting that provide additional reporting instructions. In this article, we’ve only provided a snapshot of the changes. There are plenty of other new codes that may also affect your medical practice and specialty. 

Educate physicians and other providers who document in the medical record to ensure their documentation supports the additional specificity inherent in many of the new codes. 

The new ICD-10-CM diagnosis codes have been in effect for some time. If you have not audited claims, now is a good time.

Understanding new medical codes can pose a challenge. However, with a bit of proactive planning and education, coders, physicians, and others will be able to report new codes with confidence and avoid denials.