Episode 116

Evaluation & Management (E&M) Coding 101

with Dr. Ryan Trojan and Dr. Christopher Beck

BackTable, LLC (Producer). (2021, March 19). Ep. 116 – Evaluation & Management (E&M) Coding 101 [Audio podcast]. Retrieved from https://www.backtable.com/podcasts

Dr. Ryan Trojan gives us a 101 on Evaluation and Management (E/M) Coding, including tips and tricks for capturing inpatient notes and practice building, as well as the updates for success in 2021.

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Podcast Participants

Dr. Ryan Trojan

Dr. Ryan Trojan as a practicing Interventional Radiologist with Integris Health in Oklahoma City.

Dr. Christopher Beck

Host Dr. Chris Beck is a practicing interventional radiologist with Regional Radiology Group in New Orleans.

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Show Notes

In this episode, Dr. Ryan Trojan joins Dr. Christopher Beck to discuss Evaluation and Management (E&M) coding in IR. We discuss what a practice that uses E&M looks like and the pros of integrating E&M into a practice while IR becomes more clinical. Dr. Trojan explains why he thinks relative value units (RVUs) are worth the bit of extra time. We clear up some of the misinformation about E&M, and we discuss global billing periods.

We discuss templates, Epic, and some important details about Modifier-25 for E&M. We explain medical decision making in terms of problem point, data points, and risk. We discuss the four levels of complexity and the subsets of risk. We talk through documenting history and why it is important to use straightforward language.

We discuss the most typical codes used in E&M and which codes to know for specific scenarios such as physical exams, consults, and admission. Dr. Trojan tells us some of the updates to E&M in 2021 for outpatient care. We talk about how E&M is useful when building relationships with referring doctors.


Dr. Trojan’s Youtube Video

Dr. Trojan’s Templates
Progress Notes:

Beck Outpatient Consultation:

Beck Inpatient Consult Note:

Resident Time Phrases:

Inpatient Consult:

SIR Toolkit

E&M Coding Education

Financial Advising

Medtronic Abre Stent

Learn more:

Transcript Preview

[Ryan Trojan]
So, I think the first pro is IR is moving more clinical, and so as we move more clinical, this is a huge piece. I think for practices that perform E&M, it's just better clinical care for the patients and it's a better patient experience. So, if you come see, I'm going to see you in consult, depending on the procedure, and then I'm going to see you for the procedure, and then any day you're in the hospital, I'm going to come in and see you and drop a note.

So, number one, I think it's better patient care. Number two, it's documentation. I think, especially if you're on-call on the weekends and there's a really sick patient and you decide not to intervene, then those are patients I would go see and put a consult note in so it's in the record as to why I didn't intervene. So many times interventional radiologists don't go see the patients and then stuff gets put in the chart that may not be accurate.

The third thing obvious would be increased work RV revenue. So, when you look at a vascular surgeon, for example, they get about 20% of their work RV revenue from E&M coding. I feel like as interventional radiologists we can do the same. You can have a 10% to 20% boost in your work RV revenue if you perform E&M coding.

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