June 30, 2008

IDSA’s Clinical Affairs Committee has developed a new resource to help members and their billing staffs choose the appropriate level of evaluation and management (E&M) service code.

These resources include:

• a pocket card for inpatient infectious diseases consultants on CPT coding and documentation guidelines
• a wall poster for outpatient infectious diseases physicians on CPT coding and documentation guidelines

ID physicians frequently top the Centers for Medicare and Medicaid Services’ list of coding error rates. These new resources are designed to cut down on errors. They provide systematic tables for choosing the correct level of E&M service code by following the three key steps of every visit or consultation service:

1. Determine the level of history: How much historical information about the patient’s condition is it necessary to collect?
2. Determine the level of the physical exam: How comprehensive is the exam?
3. Determine the level of medical decision-making: How does the physician rate the degree of difficulty in determining a diagnosis and treatment plan for the patient?

The pocket card and wall poster soon will be shipped to IDSA members who indicate patient care as their primary professional activity in their member profile on the IDSA website (see the “MyIDSA” tab at the top of the home page). Downloadable PDA versions of the coding resources will be accessible on the members-only section of IDSA’s website.

For more information, or to request additional copies, please contact IDSA Program Officer for Clinical Affairs Jason Scull.

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