Question: Our pediatric group practices in a community hospital, without an NICU. My pediatrician was called to attend a delivery of a newborn who was born premature and in respiratory distress. The baby needed to be stabilized and transferred to a level III neonatal intensive-care unit. The pediatrician spent 90 minutes from the time the […]
E/M Services
For many practices, E/M services are what you do the most. Knowing what type of service to bill, what level of service and the rules related to the visit will decrease denials and payment delays. Here you'll find an overview, MDM and rule changes, resources organized just like your CPT book, and a bonus section with E/M frequency data.
Coding for Prolonged Services | Webinar
Recorded April 17, 2025
Coding for prolonged services requires practitioner education, careful documentation and coder oversight. These codes are the opposite of “set and forget.” CPT and CMS use different codes and have different time thresholds. For some services, CMS allows time spent on services done on a different date!
Coding Guide – Prolonged Services
Coding for prolonged services was never easy, and CMS’s decision to use HCPCS codes and different time thresholds complicated coding. It is hardly realistic that a physician, nurse practitioner or physician assistant can keep the rules and time thresholds clearly in their head, unless they are the rare practitioner who uses prolonged care frequently. For […]
Anatomy of an Audit™
Recorded February 4th, 2025
1 CEU expire 3/30/27
Guest presenters Pam D’Apuzzo and Debra Rossi of VMG Health, and Pam Warren of MaineHealth
These two sessions take a deep dive into the audit process. Session one focuses on E/M Services, and session two, Surgical Procedures & Diagnostic Tests.
FAQ: Scoring Elements in the E/M Guidelines
Scoring MDM elements can be challenging for E/M services This post includes questions related to: Major/Minor Procedure Data Elements (with link to additional resources) General Questions about the guidelines Using Time (with link to additional resources) Social Determinants of Health Major or Minor Procedure? Question: I have a question about how to determine if a […]
The First Element of MDM: Number and Complexity of Problems Addressed
E/M elements for MDM There are three elements in medical decision-making and this article describes the first of three When selecting a level of service based on medical decision-making two of the three elements are required CPT® has developed definitions for many of the components in the MDM chart. The examples listed in the definitions […]
The Third Element of MDM: Risk of Complications
The third element of MDM: risk of complications and/or morbidity or mortality of patient management at the encounter Coding for E/M Services There are three elements in medical decision-making and this article describes the third, the risk of complications and/or morbidity or mortality related to patient management When selecting a level of service based on […]
Codes for Visits in Assisted Living (and a Visit Complexity Update for 2026!)
Question: In 2026, how will we indicate practitioners are providing longitudinal or complex care who are in assisted living or receiving services in their home? Answer: In 2023, the codes for services performed in a patient’s home or in an assisted living facility were combined to one code set. Codes (99341—99345 for new patients) and (99347—99350 […]
Acute, Uncomplicated vs. Acute with Systemic Symptoms
Question: When using the E/M guidelines, is the problem an acute, uncomplicated illness or an acute illness with systemic symptoms? Answer: Codes for Visits in Assisted Living (and a Visit Complexity Update for 2026!) Acute, uncomplicated illness Acute illness with systemic symptoms From CPT®: A recent or new short-term problem with low risk of morbidity […]
Critical Care Services
Definition and Explanation of Critical Care Service Definition: Coding service for caring for a critically ill or injured patient Explanation: Critical care has high relative value units and payments so it’s important to know the coding rules. This article describes what can be included in the time of critical care what can’t be included, and […]
Risk: Roads not Taken
How is risk assessed when selecting a level of E/M service? We know that the risk of additional diagnostic testing/procedures and management is one of the three elements that determines the level of service, when MDM is used to select a level of E/M. But, how about the risk of the condition itself? This short […]
Coding for Prolonged Services: CPT® and HCPCS Codes
Common rules: Prolonged services codes are add-on codes to the highest level E/M services in certain categories. In order to use prolonged care, the primary code must be selected based on time. This is in the CPT® and HCPCS definition of prolonged services. Prolonged services codes may only be added to the highest-level code in […]
Nursing Facility Visits
Definition Nursing facility visits are Evaluation and Management services provided in a skilled nursing facility (SNF) or a long-term care facility (LTCF) (sometimes abbreviated as NF for nursing facility. Explanation Only a physician may perform an initial nursing facility service in a SNF. This includes admissions and re-admissions. In an LTCF, a non-physician practitioner (NPP) […]
Home and Nursing Facility Category of Code Rules | Webinar
Recorded March 21st, 2024
This webinar will explain the rules for using Evaluation and Management (E/M) services (E/M) in home and residence locations and nursing and skilled nursing facilities. This includes CMS regulations for nursing facility services. It will discuss reporting multiple E/M services when one of the visits is in a nursing facility, and more.
E/M Frequency Data for Hospitalists
Hospitalists became a recognized specialty by CMS starting in 2017, and we now have frequency E/M data for the specialty. There are probably still physicians who have not switched their specialty designation. Physicians self-elect their specialty designation with Medicare and other payers. Many hospitalists are family medicine or internal medicine physicians by training, working as […]
E/M Frequency Data for Family Medicine and Internal Medicine
CMS releases E/M frequency data annually. A physician self-elects their specialty designation when enrolling with Medicare. The panel for family medicine physicians includes children, but the data below is Medicare data, for disabled patients of any age and people 65 and older. I opted to show internal medicine and family medicine together, because both are […]
Multiple E/M Services in the Same Calendar Day
The AMA added a new subsection in the 2024 E/M section addressing how to report E/M services when there are multiple encounters in the same day. (Pages 6 and 7) According to CPT® Changes 2024 An Insider’s View, the reason for this was to provide clarification for when multiple E/M services were performed on the […]
E/M Services: High Volume, High Risk | Webinar
Recorded October 19, 2023
According to CMS, E/M services comprise 40% of allowed charges in the physician fee schedule, 20% office visits and 20% other E/M services. Medicare’s expense is medical practice revenue, with the income from some primary care practices comprising 70% or more of total charges. To protect the organization, compliance professionals can focus on four components of E/M.
A Conversation with Two Auditors: Lessons Learned about MDM | Webinar
Recorded September 28, 2023
Guest Presenters Pam D’Apuzzo and Debra Rossi of VMG Health
Medical practices can prepare for audits, improve documentation and decrease compliance risk by sharpening their focus on high-risk areas, high volume services, identifying confusing areas of MDM. Then, develop consistent guidelines from appropriate resources.
Coding for Hospital Services | Webinar
Recorded April 20, 2023
First, CPT® updated their E/M code set. Then, CMS interpreted the updates and applied their own reimbursement rules to the code set. This webinar will summarize CPT® rules and CMS’s February 2023 transmittal that addresses inpatient and observation billing by the admitting and consulting physicians, admission to inpatient status following observation care, and multiple visits in a single day. The webinar will discuss when coding instruction is the same for CPT® and CMS and when it varies.
Coding Guide – Critical Care Services
The CPT® coding rules and the CMS reimbursement rules can be confusing. This guide explains the CPT® coding rules and the CMS reimbursement rules in one place.