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E/M Coding: Nail Frequently-Asked Questions on These Commonly-Billed Codes


Your pediatric practice probably reports evaluation and management (E/M) codes more than any other service, but knowing whether you’re reporting these codes correctly is paramount to collecting deserved dollars.

One of the important aspects of E/M coding is history, and a vital part of selecting the appropriate history level is nailing the provider’s review of systems (ROS) level. Without determining the appropriate ROS level, you could have trouble choosing the proper E/M code. Need help to keep ROS from becoming an issue?

Moreover, new patient rules are tricky. You need documentation of all three key components (history, exam, and MDM) to support even the lowest new patient level E/M code.

Plus, if your provider performs a prolonged, in-office E/M service with direct patient contact, coding isn’t as obvious as you might imagine.

This whitepaper provides expert advice and FAQs to ramp up your E/M coding and documentation:

  • Check out these 4 E/M FAQs.
  • Know who counts as Established patient.
  • New patient rules are tricky.
  • Can you rely on EMR codes?
  • E/M codes cover oral pain medications.
  • Read this FAQ for the 411 on ROS.
  • What is ROS? What are the different ROS levels?
  • Code prolonged service after discovering the provider.
  • Use these codes when physician, NP performs service.
  • Opt for +99415/+99416 on ‘clinical staff’ prolonged service.
  • Clinical staff questions? Call provider.


Download your FREE copy now to hone your E/M coding skills and collect your deserved dollars.