July 30, 2018

Evaluation and Management (E/M) Essentials!


Evaluation and Management (E/M) services are an everyday essential for physicians and non-physician practitioners. E/Ms account for nearly 70% of front-end charge capture process for professional billing.

Although outdated and overwhelming, the Centers for Medicaid (CMS) have published two sets of guidelines: 1995 and 1997 documentation guidelines. Physicians and non-physician practitioners are required to use one set of guidelines or the other, which can be administratively laborious due to complexities of the guidelines and potential for inappropriate upcoding.

Recently, CMS published the proposed FY19 Physician Fee Schedule.  While taking public feedback and other outreach efforts into consideration from previous years, CMS has proposed to reform the E/M documentation guidelines and payment.  It is not a matter of ‘if’, it is ‘when.’  This will occur over multi-year collaboration effort among stakeholders.  The changes will reduce clinical burden and improve documentation efficiencies to align with best practices in clinical workflows and care coordination.


  • E/M services and documentation guidelines:
    • How does your physician group compare nationally to other physicians within the same specialty?
    • Does your facility utilize ’95 or ’97 documentation guidelines, both or none?
  • Prolonged Services:
    • Does your facility charge for prolonged services?
  • Telehealth:
    • Does your facility have functionality to perform and bill for telehealth services?
  • Critical Care Services:
    • How are you billing for critical care time when multiple providers from the same and different specialties see the patient?
  • Split billing:
    • Are you providing both a preventive medicine and illness visit during the same encounter?
  • Electronic Medical Record (EMR) Functionality:
    • How are your SmartSets/templates designed to aide providers with documentation, diagnosis and charging for E/M and procedural services?
    • Are providers at your organization content or do providers find it very cumbersome to utilize the EMR tools?
    • How do you utilize your EMR to the fullest capacity for charge capture processes?
    • Beware of note bloat
      • Overly documenting history of present illness, review of systems, past, family and social history and examination to bill higher E/M levels when the medical decision making is straight-forward.

Proper E/M code assignment is focused on accurate and complete clinical documentation from providers along with comprehensive knowledge of coding guidelines supported by provider education and feedback.  Tying high caliber coding educators to clinical documentation build experts will garner success with these coding requirements.  The result is simple, but impactful…code accuracy, provider confidence in their charges, while ensuring compliance in this priority focused audit area. There is not one single answer and it continues to be laborious on practitioners to document using the outdated ’95 or ’97 E/M documentation guidelines while maintaining current clinical volumes and quality metrics.

Whether or not CMS’ proposals come to fruition, let The Wilshire Group assist with designing a comprehensive approach to coding and clinical documentation setting your providers and health system up for success with the everyday E/M essentials.


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