Making Sense of
Evaluation and Management
Effective evaluation and management coding, also known as E/M coding, is key to maximizing reimbursement and maintaining proper documentation. Many physicians lose revenue every day because they undercode their services.
The CPT codes that describe the physician patient encounter are referred to as evaluation and management codes or, more commonly E/M codes. The codes vary depending on the location of the encounter, in the hospital or office, or whether it
is an initial or established patient visit. Within each type of visit, there are different levels of care. The fifth digit of the CPT code ends in the numbers 1 through 5, 1 being the lowest level of care and 5 being the highest. For example, the patient's first office visit at "level 2" has an E/M CPT code of 99202. An established patient office visit at "level 4" is coded 99214.
The documentation for evaluation and management coding are based on: