E & M Nursing Codes: A Case Study

Accurate documentation in clinical practice is a significant component of the delivery of quality patient care. Evaluation and management (E&M) codes comprise to assist providers adequately . In order to receive reimbursement from health insurance companies, APNs must accurately use E&M codes to bill for services they provide during patient encounters. Hence, the significance for APNs to be knowledgeable in the use of E&M codes to bill for patient care services provided and stay abreast on current and future guidelines. For new APNs, understanding the history, purpose, and components of E&M coding is fundamental in avoiding legal and ethical dilemmas that may arise throughout their practice. The following discussion will address the issues
The word evaluation as it pertains to healthcare means to analyze a patient’s ailment, assess its criticality and determine its solution. Management in the outpatient setting entails the diagnostic workup and application of identified interventions to the patient’s illness while monitoring for deterioration or improvement of their symptoms. Evaluation and management codes combine the above definition into one concept used by providers to bill for outpatient services. Although E&M codes did not emerge until 1992, the concept evolved from the 1960 first edition of the American Medical Association’s Current Procedural Terminology (CPT) Manual. The first CPT Manual emphasized a consistent way to document procedures across various specialties. Later in 1970, internal medicine services were added to the CPT procedures and described office visits and various tiers for service
The HPI consist of 8 elements and can be either a brief or extended narrative describing the sequence of events related to the presenting illness (Schmidt, 2011; Brame, 2014). The provider documents the patient’s report of the illness from the onset of the symptoms to the time of the visit and may also include relevant information from a previous visit. The HPI documentation must include one of eight elements describing the a) location of the body affected by symptoms, b) quality of the pain, c) severity of the pain on a scale of 1-10 with the latter being the worst pain, d) duration or the onset of symptoms, e) timing, or how often the pain is noticed f) context or activity of g) modifying or alleviating factors, and h) related signs and symptoms, the provider must include one to three elements when completing a brief note, or four to eight elements when completing an extended