There is often risk involved in medical care, either from the treatment given to the patient or from the lack of treatment and professional care. Morbidity, the relative incidence  of disease, and mortality, which relates to the number of deaths from a given disease, are part of the assessment of risks made by the physician.

These three elements play a role in the complexity of the decision-making process used when treating a patient. The physician determines the level of care given to a patient, but must consider these three factors when choosing the E&M levels assigned to a patient on a given encounter. The physician cannot base the choice of E&M levels solely on the time spent with the patient. All elements must be considered when assigning the code. Usually, the physician circles this service code and other procedure codes on the encounter form as or just after the patient is seen in the office. Although a physician may allow the medical assistant to make notations on the encounter form, only the physician makes the decision as to which services and procedures are performed.


Straightforward:  Minimal diagnosis/management options, minimal/none for the amount and complexity

of data to be reviewed, and minimal risk to the patient of complications or death if untreated.

Low-complexity:  Limited number of diagnoses/ management options, limited data to be reviewed, and low risk to the patient of complications or death if untreated.

Moderate-complexity:  Multiple diagnoses/management options, moderate amount and complexity of data to be reviewed, and moderate risk to the patient of complications or death if untreated.

High-complexity:  Extensive diagnoses/management options, extensive amount and complexity of data to be reviewed, and high risk to the patient for com­plications and/or death if the problem is untreated.


The examination is the objective part of the patient's visit. The physician examines the patient and makes notes referring to body areas and/or organ systems:

Body areas:  Head including face and neck, chest, including breasts and axillas, abdomen, genitouri­nary (GU), back, including spine and extremities.

Organ systems:  Constitutional, eyes, ears/nose/throat and mouth, cardiovascular, respiratory, gastrointestinal (Gl), GU, musculoskeletal, skin, neurological, psychiatric, and hematological/lymphatic/immunologic.

The examination is divided into the following levels:

Problem focused:  The examination is limited to the single body area or single system mentioned in the chief complaint.

Expanded problem focused:  In addition to the limited body area or system, related body areas or organ systems are examined.

Detailed:  An extended examination is performed on the related body areas or organ systems.

Comprehensive:  A "complete" multi-system examina­tion is performed.


Although the determining factors just discussed are the basis for E&M coding, there are circumstances in which other factors contribute to determining the level of service.

Counseling.  Almost all E&M services contain a degree of counseling with the patient and/or the family. This is factored into the E&M code, and as long as this factor does not exceed 50 % of the time spent with the patient, it is included in the E&M code.

Coordination of Care.  Some patients need assis­tance in arranging for care beyond the visit or hospi­talization. Some will need care in a skilled nursing facility or home health care. Others will need hospice care. The primary physician usually coordinates this care.

Nature of the Presenting Problem.  The presenting problem is usually explained in the chief complaint. It can range from something as simple as a cold in an otherwise healthy patient to a life-threatening problem.

Time.  CPT has provided assigned times for each of the CPT E&M codes. Time should not be the determining factor, with one exception: if more than 50 % of the visit is spent counseling, only time determines the level of complexity.


  1. Determine whether the patient is new or established.
  2. Where is the patient being seen-office, hospital, or other setting?
  3. Is this a patient of the practice, or is someone requesting a consultation?
  4. Is the patient "sick" or here for preventative medicine services?

5.      Is the history problem-focused, expanded problem-focused, detailed, or comprehensive?

6.      Is the examination problem-focused, expanded problem-focused, detailed, or comprehensive?

  1. Is medical decision making straightforward, low, moderate, or high?
  2. Pick the code.

CPT Coding Definitions

Bundled codes describe procedures or services that are grouped together and paid as one. An example would be code 90700 Diphtheria, tetanus toxoids, and acellular pertussis vaccine for intramuscular use.

Unbundled codes describe separating the components of a procedure and reporting them separately. To use the diphtheria example, if someone reports the three vaccines separately, it gives the impression that three injections rather than one were given.

Upcoding is a deliberate increase in a CPT code to receive higher reimbursements. This is a target of CMS investigations and should never be done.

Downcoding is usually done by the insurance companies if, on review, the examiner feels the documentation does not match the code description.


If a patient was referred for epigastric pain and if; Shuman performed an ultrasound  examination of the gallbladder, what would Kay need to consider to properly code this encounter?


      Always have the latest edition of CPT and HCPCS. . Follow the “CCI” information quarterly. . Never code something because it is "close" to the description; research it further.

      Review the guidelines and refer to them as part of your routine. It would be extremely difficult for anyone person to know all the specific guidelines.

      Keep the lines of communication open with the physician and never hesitate to ask for clarification.

      Develop am! use an audit sheet that you are comfortable with and do periodic code reviews. This may not be your responsibility, but understanding how a chart auditis done can help you in your coding responsibilities.

      Know the modifiers and use them when appropriate.

      Know abbreviations, especially for laboratory procedures.

 Legal  and Ethical Issues

Medical assistants must be responsible and remain knowl­edgeable about CPT to ensure that no fraud takes place in the coding and claims submission process. Medical assis­tants should also ensure that proper precautions are taken to avoid incorrect coding, data entry errors, and false claims submissions.

Codes or narratives should not be altered in patient chart documentation to increase insurance reimburse­ment or to accommodate policy coverage requirements. Deliberate misrepresentation may carry criminal and/or civil penalties

Post a Comment

Webmaster reserves the rights to edit/remove comments that is found irrelevant, offensive, contain profanity, serves as spam or attempts to harbor irrelevant links. Please read our Comments Policy for details.