Part 1: 2023 Evaluation and Management Series by AMCI

Introduction

This tutorial provides a comprehensive overview of Evaluation and Management (E/M) coding as outlined in the 2023 guidelines. It is designed for students and professionals interested in mastering E/M coding concepts, from the basics to advanced guidelines. By following this guide, you will gain insights into key terms, code selection, medical decision-making, and the intricacies of E/M coding.

Step 1: Understand Basic E/M Coding Concepts

• Familiarize yourself with E/M coding principles, focusing on the purpose of E/M codes in medical documentation.
• Review the key components of E/M services, which include:
  • History
  • Examination
  • Medical decision making (MDM)
• Identify the different types of E/M services, such as office visits, hospital visits, and consultations.

Step 2: Review Key Terms in E/M Coding

• Learn important terminology related to E/M coding:
  • CPT: Current Procedural Terminology, a set of codes used to describe medical services.
  • MDM: Medical Decision Making, a critical factor in determining the complexity of care.
  • CHUN: A mnemonic representing the components of key E/M coding elements: Complexity, History, Understanding, and Necessity.

Step 3: Master Medical Decision Making Scoring

• Study the criteria for scoring MDM:
  • Assess the number and complexity of problems addressed during the visit.
  • Evaluate the amount and complexity of data reviewed and analyzed.
  • Determine the risk of complications and/or morbidity or mortality.

Step 4: Learn Code Selection Guidelines

• Follow the updated guidelines for selecting the appropriate E/M code based on:
  • The type of visit (new vs. established patient).
  • The level of service provided (low, moderate, or high complexity).
• Use the E/M code selection matrix to navigate through various codes.

Step 5: Familiarize Yourself with Advanced E/M Guidelines

• Explore advanced concepts that are essential for accurate coding:
  • Time-based coding vs. medical decision-making-based coding.
  • Specific documentation requirements for different types of encounters, including telehealth services.

Step 6: Prepare for Practical Application

• Review scenarios and case studies to apply your knowledge of E/M coding.
• Engage in practice coding exercises to reinforce your understanding.
• Utilize resources such as AMCI’s E/M Group Studies for further learning and collaboration.

Conclusion

By following these steps, you will gain a solid foundation in Evaluation and Management coding according to the 2023 guidelines. Focus on understanding the fundamental concepts, terminology, MDM scoring, and code selection to prepare for real-world applications in medical coding. As you advance, consider participating in group studies or additional training to deepen your expertise.