E/M Coding

E/M Coding is a methodology that refers to Evaluation and Management coding in the medical industry.  In a more definitive sense, it refers to ensuring that the correct procedure code is selected for a patient visit based on a range of factors.  

Some might look to their EMR software solution to assist with this E/M process outside of standard billing practices in so that their software provide an option to make intuitive recommendations on their billing code selection for patient visits based on a variety of factors, not limited to length of time of the visit or the complexity of the encounter. 

In 2021, some changes have taken effect for E/M services specifically related to office visit procedure codes in an effort to ensure that the most face time spent with a patient is of value and less time is spent on administrative work.  The role our EMR plays in this is already prepared to handle these 2021 changes.  While MacPractice cannot intuit a specific need for a procedure code based on appointment time or chart notes, it does have the functionality to provide everything a provider needs to follow protocol for handling E/M services to date.  

The specific changes to coding requirements for E/M in 2021 are ensuring a provider and biller select the correct office visit code based on the total time spent with a patient. MacPractice support can assist by showing an office where to enter procedure codes, by modifying careslips to pertain to certain office visits in a certain order for billing intuitiveness, and by adding note and details to fee schedule fee descriptions to identify more easily.