title: A case-based approach to outpatient evaluation and management service coding.
abstract: 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.
authors.affiliation: Department of Medicine, University of Washington, Seattle, WA 98195, USA. staiger@u.washington.edu
authors.forename: Thomas O
authors.initials: TO
authors.lastname: Staiger
authors.forename: Lisa D
authors.initials: LD
authors.lastname: Chew
authors.forename: Ira
authors.initials: I
authors.lastname: Helenius
mesh_terms: D000553:Ambulatory Care; D014487:Centers for Medicare and Medicaid Services, U.S.; D005568:Forms and Records Control / Q000458:organization & administration*; D006801:Humans; D007344:Insurance Claim Reporting; D008297:Male; D008499:Medical Records; D014481:United States