What is the first step to determining the correct E/M code?

What is the first step to determining the correct E/M code?

• A. Determine the category or subcategory of service
• B. Count the diagnoses
• C. Review the payer's policy
• D. Assess patient age

Answer: (A)

Determining the category or subcategory of service is the starting point because E/M codes are organized by setting and type of visit (office/outpatient, hospital, etc.). Identifying the category tells you which coding guidelines apply and which documentation elements you’ll use to pick the correct level. Once you know the category, you then evaluate the chart for history, exam, and medical decision making within that category to determine the exact level. Counting diagnoses is part of understanding medical decision making, but it isn’t the first step. Reviewing payer policy is important for coverage and exceptions, but it doesn’t establish the correct category. Patient age rarely changes the initial categorization, though some pediatric considerations can affect which codes are available within the category.

Determining the category or subcategory of service is the starting point because E/M codes are organized by setting and type of visit (office/outpatient, hospital, etc.). Identifying the category tells you which coding guidelines apply and which documentation elements you’ll use to pick the correct level. Once you know the category, you then evaluate the chart for history, exam, and medical decision making within that category to determine the exact level.

Counting diagnoses is part of understanding medical decision making, but it isn’t the first step. Reviewing payer policy is important for coverage and exceptions, but it doesn’t establish the correct category. Patient age rarely changes the initial categorization, though some pediatric considerations can affect which codes are available within the category.