Evaluation & Management (E&M) Coding 101

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.