Dr. Jeff Lehrman, I am a podiatrist, and a certified professional coder, and a certified professional medical auditor. I see patients in Fort Collins, Colorado, which is 1 hour north of Denver, and I operate a firm that provides guidance regarding coding, compliance, and documentation.

E&M—A N D—and I say that because some people say E N, like the letter N, and so E&M stands for Evaluation and Management, and it is important to differentiate between an Evaluation and Management and a Procedure. So every service we provide, it's almost every service we provide, it's either an evaluation of management or a procedure. Let's do procedure first because I think it's easier.

Procedure is when we use our hands to do something to another person. Cut something, incise something, drain something, operate something, inject something, those are procedures. An evaluation and management is when we evaluate a chief complaint by taking a history and performing an exam. That's the E of the E&M. And the M is using the provider's expertise, training, and peer-reviewed literature to manage. And forms of management are education, making a recommendation, writing a prescription, making a referral, ordering a study, using the provider's education and expertise to somehow manage that problem. And I'm stressing the M because some people in their documentation make the error of only capturing the E where the M is important.

So again, procedures using our hands to do something to another person versus the evaluation and management that we just described. So a good example in wound care might be if a person comes in with an ulcer that needs a debridement, that's of course a procedure, we could have another situation where the patient presents and it's infected and no debridement is needed and instead it's all about the infection, the cellulitis, where we perform the E by taking the history. How long has it been like that? Does it hurt? Does it look different than it did 48 hours ago? And asking all of those questions. And then the management, which might be changing what they're using topically, changing the offloading device, making different recommendations, writing a prescription for an antimicrobial agent. And those are all Ms; that's the "M" of the E and M. So if we only E&M’d the cellulitis, that would be an E&M.

Another example might be, we see the person, no procedure, doesn't need a debridement today, and we change their offloading device, perhaps, or graduate them to something else. Or another really good example, is when it's healed. They don't know it's healed until we tell them it's healed. In many cases, plantar foot, patients can't see it they don't know. And the patient might say, “I'm not seeing any more drainage on my bandage.” And it requires us to evaluate it to really investigate the quality of the tissue, is it actually healed, and it's up to the doctor to decide you don't need your bandage anymore or you can return to normal shoes now. So that visit where we see them,, and make that determination and manage by saying, “You can change this, and you don't have to do that, and now you can accelerate whatever,” that's another good E&M example. 

So, we're talking about application of cellular or tissue-based products for wounds, the terminology with skin substitute gets weird, but we all know what we're talking about. If a patient comes in for a…there is gray to be fair, but for teaching purposes, for explaining purposes, we'll stick with the black and white. If the patient is scheduled for a CTP or skin substitute, whatever the person calls it, application, and they come in and say we set this up last week. The thing is here, we're going to put that product on today, and we cleanse it and prepare it and apply it and fixate it and dress it. That's a procedure. There's no E&M there. So the skin substitute application, CTP application, is a procedure, and if what I just described is what happens at the encounter, there's no evaluation and management coding and only procedure coding. And possibly the product.

So I said at the beginning, almost every time we provide a service, we see a patient, it's either a procedure or an evaluation and management. It is essential for good documentation and for submitting claims to third-party payers that the documentation clearly differentiates what happened and whether it was a procedure or it was an evaluation and management. I find providers are typically better with the procedure side and we're normally really good at an op note and describing a debridement. If an evaluation and management is performed, it is important to document both the E and the M, evaluation being the components of the history. Some of us might think of like nature, location, duration, onset, the mnemonic that some of us learned in school, and past medical, social, family, allergy, stuff like that, and then of course the physical exam. And the M. That's what so many miss in the documentation. And this is good risk management too.

Thought process, what was considered, what decisions were made, why did we make those decisions. That's good care, it's good documentation, it helps with consistency of care if another provider should see this patient, and it's really important from a risk management standpoint, and when it comes to supporting our submission of an evaluation and management code, the documentation needs to have that meat of both the E and the M. And to the providers watching this, don't be afraid to explain all of that M. I think some people get hung up in thinking it has to be all fancy doctor language, which that's fine, but it doesn't have to be. Thought process is good, right? It's good to explain, this can be in the note: the patient had this, we considered a, b, and c, b is not a great option because of this, we talked about a, but they thought that wasn't realistic because they have to drive and it's their right foot, so we've considered c, and that thought process is really important and useful for lots of reasons.