General Issues in Evaluation and Management (E&M) in Headache

By better understanding the Evaluation and Management (E/M) coding system and rules, it is the physician’s challenge to meet the demands of a complex health care system while still providing excellent patient care. While physicians are faced with multiple challenges to meet these demands, quality care of our patients is still the central theme and the reason why we became physicians. A working knowledge of the E/M methodology unites the goal of quality patient care and conformity to the Current Procedural Terminology (CPT) and International Classification of Diseases (ICD)
regulations. A thorough understanding of the CPT coding system is essential in order to provide accurate reporting of medical services and procedures and to correctly describe medical, surgical, and diagnostic services among physicians, coders, patients, accreditation organizations, and payers for administrative, financial, and analytical purposes. Accurate ICD codes provide The Centers for Medicare and Medicaid Services (CMS) and other third – party insurance carriers correct and complete coding to the third, fourth, or fifth digit.

In this series posted on the American Headache Society website, the CPT coding fundamentals and ICD coding recommendations for headache patients will be reviewed.New sections will be posted quarterly. This initial segment will focus on some general and important issues regarding CPT coding.
Identifying the proper CPT code exemplifies the traditional paradigm of documenting the physician’s care then trying to identify the code for the level of service provided. To help insure more accurate coding, there are some key points regarding the CPT coding system which are worth reviewing. When the AMA first developed and published the CPT nomenclature in 1966, a four – digit system was used. The second CPT edition published in 1970 presented an expanded system of terms and codes to designate diagnostic and therapeutic procedures. It was at that time that the five – digit codes
were introduced. Currently, all CPT codes are five digit codes. CPT codes are revised and updated annually by the AMA and the revisions become effective each January 1st. Since hundreds of CPT codes are added, changed, or deleted each year, it is important for all health care professionals to maintain copies of the current code books. The CPT coding system includes thousands of codes and definitions for medical services, procedures and diagnostic tests. Category 1 CPT codes describe a procedure or service identified with a five – digit numeric CPT code and descriptor nomenclature.
These codes are based on the procedure being consistent with contemporary medical practice and being performed by many physicians in clinical practice in multiple locations. Category 1 CPT codes are restricted to clinically recognized and generally accepted services, not emerging technologies, services, and procedures. All of the E/M codes are included in Category 1. Two additional CPT code categories debuted in 2002. Category 11 CPT codes are a set of optional codes developed principally to support performance measurement. These codes are intended to facilitate data collection, do
not have a relative value associated with them, and are not required for correct E/M coding. Category 11 codes have been developed for following the care and good outcomes in certain clinical conditions such as: asthma, chronic stable coronary artery disease, congestive heart failure, hypertension, osteoarthritis, prenatal care and preventive care. There are also Category 111 CPT codes which are temporary codes used for emerging technology, services and procedures. These codes may be covered by given carriers if prearranged but are not covered by Medicare.