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E&M documentation and coding processes for Neurology

Evaluation and Management codes (E&M codes) are a group of CPT codes used while evaluating and managing patient health. Apart from regular neurology codes, coders working in this specialization for various medical coding service companies should also be aware of E&M codes to ensure they are able to bill for services precisely and avoid denials and claim rejections.

The initial consultation and diagnosis steps in any primary care, specialty clinic, or multi-specialty hospital require using E&M codes.

Any medical coding services company that works for neurology clients needs to be aware of the changes in the CPT E&M code guidelines changes that were initiated in January 2023. Being aware of these changes can be the difference between precise and problem-free coding and codes that lead to denials.

E&M neurology coding – documentation process

There are five basic features of E&M neurology documentation that all medical coding services companies need to follow.

1. Recording history
2. Detailed physical examination
3. Recording time
4. Type of patients
5. Medical Decision-Making (MDM)

1. Recording history
Recording history involves understanding and documenting the present signs and symptoms and recording the past history of the condition. Medically relevant family and social history are also collected and documented in this step.

2. Detailed physical examination
A physical examination will be done by the attending neurology physician, who will use clinical judgment to understand the existing problem. The physicians document their impressions and diagnoses, and this document will be passed on to the internal coding team or the third-party medical coding services company, who will then convert the document into codes that the insurance payers can understand.

3. Recording time
One of the important factors to document, which will directly affect the codes generated, is encounter time. Since the service providers are paid for their time spent in treatment and diagnoses, recording this helps get appropriate reimbursements.

Coders belonging to the third-party medical coding services company will need the below encounter time details to generate the right CPT codes.

• Initial preparation before meeting patient
• Time spent obtaining the history
• Actual time spent in physical examination and evaluation
• Meeting with family members/counseling
• Ordering diagnostic tests or reports
• Time spent in clinical documentation
• Analyzing results or reports
• Getting in touch with other specialists regarding the patient

4. Type of patients
There are two types of patients that coders need to check in the documentation process. New patients are someone who hasn’t visited the physician or the practice in the last three years. Established patients are recurring patients for the physician or the practice.

5. Medical Decision Making (MDM)
MDM is the most important factor that, at the end of the day, determines what codes the medical coding services company decides to generate for the claim. It is to be noted that the claim value will increase or decrease depending on the level of intensity of the case.

There are three factors that coders should look for while determining MDM

a. Risk

Risk is determined based on how complex or critical the presenting problem is, the presence of new neurological conditions, and the status of the patient. There are four levels of risks noted – high, moderate, low, and minimal.

For instance, an existing patient visiting the doctor with sudden bursts of headaches will be put under the high-risk category because there is a new severe symptom added.

In the case of a patient visiting the doctor for a minor side-effect of an existing drug, the medical coding services company may choose a minimal-risk category for this.

b. Management options

Management options are determined based on whether the patient encounters new physical problems, if an existing condition is stable or has worsened, and the future treatment plan specified. There are four categories for the coders to choose from here – minimal, limited, multiple, and extensive.

An extensive management category would be for a patient who walks in with a new problem that’s severe, and the doctor has new tests and workups planned to address the condition.

c. Complexity of data

The complexity of data is determined by the medical coding services company depending on how much data the physician has to wade through to offer an interpretation and conclusion of the condition. The data could include past test results and reports, new test results and reports, discussions with other physicians, and outside reports and images.

There are four levels of complexity noted – minimal, limited, moderate, and extensive.

Now, there are four levels of MDM identified by the coders, depending on the risk, management, and complexity of data.

High complexity – high risk, extensive management, and extensive complexity of data
Moderate complexity – moderate risk, multiple management, moderate complexity of data
Low complexity – Low risk, limited management, limited complexity of data
Straightforward – minimal risk, minimal management, minimal complexity of data

The importance of understanding E&M documentation and codes

Both medical coding service companies and in-house coding teams need to spend time in understanding the basics of E&M documentation and codes for neurology practices. Incorrect submission of claims can lead to denials, rejections, and even civil/criminal penalties.

With the E&M code regulations changed as of January 2023, medical coding service companies should have invested in training and learning programs for their billers and coders to stay aware of the changes.


Neurology billing and coding is complex and quite challenging, and that is why billers and coders adept in this department are in constant demand and are compensated well too. Apart from process-related codes, neurology coders should also be aware of E&M codes and the challenges in getting that right.

Medical coding service companies need to invest resources in helping their coders learn about Medical Decision-Making and the importance of getting that right. This will help their neurology clients get paid fully and quickly.

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