Evaluation & Management Coding Guidelines

Evaluation and Management Coding Guidelines define the way physicians report and bill for medical services.  These guidelines establish what documentation is needed to bill for medical history-taking, physical examinations and medical decision making.

The level of evaluation and management service a physician chooses is based on the documentation and the medical necessity of the services provided.  The service selected is defined by the:

• type of service (consult or new patient);
• type of patient (new or established); and
• location of service (inpatient or outpatient).

For more detailed information, please visit the following links:

• Documentation Guidelines for Evaluation and Management (E/M) Services
• Medical Learning Network (MLN) products overview page
• Preventive Medicine Services
• New Patient vs. Consultation
• Evaluation & Management Services Guide - 1995 Exam Guideline
• Evaluation & Management Services Guide - 1997 Exam Guideline

In order for the teaching physician to bill for the service, the billing physician must document according to the CMS Guidelines for Teaching Physicians, Interns and Residents.

Coding Links from the Center for Medicare and Medicaid Services

• ICD-10-CM Codes
• HCPCS Codes
• Medicare Learning Network (MLN)

Billing and Documentation Guidelines

Medical record documentation is required to record pertinent facts, findings, and observations about an individual's health history including past and present illnesses, examinations, tests, treatments, and outcomes. The record should chronologically document the care of the patient, and is an important element contributing to the quality of care. The medical record is also considered to be the basis for assessing patient health over time; appropriate utilization review and comparisons, a data source for research and education; a legal document for risk management; and establishes the supporting elements needed for professional fee billing.

As a general rule, physicians must clearly document (in legible handwriting or in a signed dictated note) their presence, and level of participation in the services provided. Medical record documentation should be completed immediately following patient services or within sufficient time to recollect the key portions of the services provided in accordance with regulations following medical staff policies and procedures. Whoever dictates a note, report, or entry, shall sign that note, report, or entry. A medical record is considered a legal document; therefore, handwritten entries must be made in ink and must be legible.

Billing Links

• California Medicare Part B Contractor: NHIC - Noridian
• Advance Beneficiary Notice (ABN) Decision Tree
• Medicare Advance Beneficiary Notice (ABN) Complete Guide

Diagnosis (ICD-10-CM) Coding

The CPT code or service is the driving force behind reimbursement. However, the ICD-10 diagnosis code must support the CPT code in order to reflect medical necessity.

The system of diagnosis codes used is the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10 CM)

The primary diagnosis must support or justify the physician's service. For instance, the impatient consultant's primary diagnosis would be the reason for the consult and not necessarily the admitting diagnosis.

The highest level of specificity should be given when establishing a diagnosis. Sites of injuries, infections, and burns should be provided. The claim should be as clean as possible. Therefore, try to avoid unspecified diagnoses and codes.

The highest level of certainty should be given when establishing the billing diagnosis. "Suspected" or "rule out" diagnoses cannot be coded. If the physician is working only with phenomena and has not yet formed a diagnosis, then the sign, symptom, or laboratory abnormality should be selected.

Document all conditions that coexist at the time of the visit that require of affect patient care, treatment or management. Conditions that were previously treated and no longer exist should not be coded.

Avoiding Conflicts of Interest

Because of the potential for abuse, having a financial interest that conflicts with the role you have within UCR Health is of concern, even if you have good intentions, never exploit the conflict, and do not harm anyone.

UC Riverside employees are government employees. California has special conflict of interest laws and regulations affecting government employees.  In addition, Federal law has special sections relating to health care conflicts of interest that result in more stringent standards than for most other businesses. This all adds up to a set of strict standards every one of us must follow.

As a matter of policy, UC Riverside Health discourages the existence of potential conflicts of interest. Such conflicts may make it difficult for an employee to discharge his or her work duties.

AMA Conflict of Interest Code

The American Medical Association (AMA) has an extensive code of ethics, which includes several sections concerning conflicts of interest.

NIH Conflict of Interest website

The National Institutes of Health website contains links and information on conflicts of interest, including a report on the strengths and weaknesses of institutional policies.

Vendor Relations

All employees and students of the University of California are subject to the conflict of interest provisions of the California Political Reform Act and the University of California policies related to purchasing and procurement (Business and Finance Bulletin G-39). The UC Health Care Vendor Relations policy supplements these policies by providing system-wide standards aimed at reducing the potential for industry influence on health care providers’ decisions.

Information for Researchers

The Office of Research and Economic Development (RED)

The Office of Research and Economic Development (RED) works with faculty, schools, and organizations to launch research collaborations, increase federal research funding, facilitate technology commercialization and start-up ventures, and to ensure compliance with federal and state regulations.

Office of Technology Partnerships (OTP)

The Office of Technology Partnerships (OTP) helps individuals in the UCR and the Riverside communities who have ideas or technology they want to develop, protect, fund, or commercialize. OTP’s team of experts in commercialization, research collaboration, and entrepreneurial education use a personalized approach to help individuals and teams identify and achieve their goals.

Entrepreneurial Proof of Concept and Innovation Center (EPIC)

In collaboration with the Riverside County Economic Development Agency and numerous regional partners, the Entrepreneurial Proof of Concept and Innovation Center (EPIC) provides training, resources, and incubator space for UCR and Riverside-based innovators and startup companies.

List of Excluded Individual and Entities and List of Parties Debarred from Federal Programs

The Office of Inspector General (OIG) has the authority to exclude individuals and entities from federally funded health care programs pursuant to sections 1128 and 1156 of the Social Security Act and maintains a list of all currently excluded individuals and entities called the List of Excluded Individuals and Entities (LEIE). Anyone who hires an individual or entity on the LEIE may be subject to civil monetary penalties.

The effect of an exclusion (not being able to participate) is:

• No program payment will be made for any items or services furnished, ordered, or prescribed by an excluded individual or entity under the Medicare (Title XVIII), Medicaid (Title XIX), Maternal and Child Health Services Block Grant (Title V), Block Grants to States for Social Services (Title XX) and State Children's Health Insurance (Title XXI) programs during the period of exclusion.
• No program payment will be made to any entity in which an excluded individual is serving as an employee, administrator, operator, or in any other capacity, for any services, including administrative and management services furnished, ordered, or prescribed during the period of exclusion.
• No payment will be made to any business or facility, e.g., a hospital, that submits bills for payment of items or services provided by an excluded party.