Laureen: How to Level an E&M Code:
Q: Would it be possible to briefly go over your E&M leveling tool? Where I work, the
providers level the visits. I code all diagnosis codes and add the appropriate modifiers.
So I’m really weak on being able to level E&M.
A: I can’t promise the briefly part, but I will definitely share my technique for doing
E&M leveling. Basically, this is a system I teach, this
is actually how I got in doing my “Review Blitz,” I started tutoring people that were
struggling with E&M back in the day. I took my exam in 1999, the E&M questions on the
board were like 25, now they’re 10. So a lot of people were failing the exam just because
of the E&M, so I would do tutoring and then I came up with this system and it really worked
and so many students were like, “I finally get E&M!” So, hopefully, you’ll get that
“aha!” moment tonight. If not, we do have a three hour class on E&M that’s on “On
Demand” and it’s this system that I go over in a little bit slower.
One of the first things that I would teach you to do, if you’re one of my students
is to mark up your E&M section of your CPT manual. I’m a very visual learner, I need
visual cues to help me; so, I did this to help myself.
So, the four possible letters that you would be writing next to your History Bullet is
PEDC and the same for Exam, which stands for Problem Focused, Expanded Problem Focused,
Detailed or Comprehensive. And then, SLMH for the Medical Decision Making, which stands
for Straightforward, Low, Moderate, High. Then, the other notation that you want to
make is whether or not the particular code is a “3 of 3” code or “2 of 3” code.
I’m going to explain all this, so if you’re scratching your head, hang with me here.
My system, what I call it is “Locate your HEM and Time.” It’s the little rhyme that
I teach my students and I actually tell them on their exam booklets or in real world, a
scratch piece of paper, Post-It, or whatever, write this down: Locate ___ (with a line next
to it), H, E, M all with their own line, which stands for History, Exam, and Medical Decision
Making – which are the three key elements of E&M coding and then Time. Sometimes, Time
can be the controlling factor, not the HEM (History, Exam, and Medical Decision Making).
The “locate” of course is the category and sub-category of the E&M: Was it an office
new patient? Was it a hospital ER? That sort of thing.
So when I do these lectures, I spend an hour-plus just going over the categories and sub-categories
because I like to say, “You need to get in the right church and the right pew. You
could be in the right pew but the wrong church.” We have to find the right church first for
the “locate.” Once we’re there and we’ve narrowed it down, for example, to “office”
we know that the location was “office” and now we just need to know is it a new patient
or an established, so then we pick accordingly. Let me show you that. Here’s a blown-up
view of one E&M from my manual, and I just picked 99343. We’ve got three bulleted key
components here. They always are the same for E&M, History will always be the first
bullet, Exam will always be the second bullet, and Medical Decision Making will always be
the third bullet; so the type of E&M code that has bullets, they’ll always be in this
order. Because this particular code was a Detailed
history – I wrote a “D” next to it – the Detailed Exam – so I wrote a “D” next
to it – Moderate Medical Decision Making – I wrote an “M.” You got to be careful
with the Medical Decision Making because the controlling word is toward the end of the
line, so don’t pick “M” for “Medical.” So this one becomes DDM, it’s shorthand.
If you were writing this on your exam booklet or on a Post-It note for a real case, now
you’re going to start seeing these choices. So here it was DDM, so we would have had a
D, a D and an M. Let’s look at them as a group, so we’ve
narrowed it down to we’re dealing with a new patient, so there’s a new office patient.
There are only five choices or what people like to call “levels” and that is why
this is called “leveling.” 99201 – Also known as level one. If you
were to define it using my system, it would be called PPS. Your level two would be an
EES (for expanded problem focused, expanded problem focused, straightforward). Your level
three would be a DDL (detailed, detailed, low). Your level four would be CCM (comprehensive,
comprehensive, moderate). Then your level five would be CCH (comprehensive, comprehensive,
high). So, just looking at the first bullet, you
can start to see the hierarchy. You’ve got PEDC and then C again, so of course E&M coding
can’t be easy and have four codes because there’s four choices for each History, Exam,
and Medical Decision Making. They got to have five levels and that’s not true of all of
the categories and subcategories, but for a lot of them it is.
Now, look at the second bullet. This is for the Exam element. We got problem focused,
expanded problem focused, detailed, comprehensive, comprehensive. It actually follows the pattern
that the History one did. Now, this is what’s it like for a new office patient, but for
another category and subcategory that has five levels, it is sometimes different so you can’t even say a problem focused is always a level one. Oftentimes it’s true, but you
can’t even have a hard-and-fast set of rules for that, so you really have to do them individually.
Then, the last bullet for Medical Decision Making, always “S” for “straightforward”
comes first. Now you’ll notice with this one, the “S” shows up on the level one
and the level two
and then it goes low, moderate, high. So you
need to understand that hierarchy. So PEDC, PEDC, SLMH; and so, when you’re reading
a scenario you’re trying to pull out that information that you can add it on these lines.
On the board exam, quite often, it used to be all of them but I think it’s only 8 out
the 10 questions from what I’m hearing from people taking it, where they actually tell
you the physician did an expanded problem focused history. So you’re going to circle
“E” and exam, so you’ve got EE and made moderate medical decision making – so EEM.
You’re going to abstract that information from the scenario. Now, in the real world,
physicians don’t do that; but because E&M is so complicated and the CPC exam is testing
you on a broad-based of knowledge, they normally
will tell you what the history score is or the history level is. They want to see if
you were able to figure out the overall level.