Coding Updates Details

Accuracy in coding for Evaluation and Management is a crucial factor for coders. Coding incorrectly or reporting with wrong documentation for E/M services can be a major cause of concern for the coders. Incorrect documentation can lead to major compliance violations and may cause loss of income for the physicians. Hence, the coder is required to understand the requirements of E/M documentation guidelines and the procedure to prepare correct documentation. Let us now see the main components of E/M documentation.

Challenges faced by Practices while coding for E/M services

Main Components of E/M Documentation

The documentation for E/M services is based on three components:

• History
• Physical Exam
• Medical Decision-Making

History :

Medical history provides information about the clinical problems/symptoms addressed during the encounter.

Physical Exam :

Similar to the levels of history, the physical exam documentation also requires four levels, viz. Problem focused, Expanded problem focused, Detailed and Comprehensive.

Medical Decision-Making (MDM) :

MDM is considerably the most important component of E/M documentation as it reflects the intensity of the cognitive labor performed by the physician. There are four levels of MDM of incrementally increasing complexity, viz. Straightforward, Low Complexity, Moderate Complexity, and High Complexity. These complexities must be stratified based on the nature and number of clinical problems, the amount and complexity in the data as reviewed by the physician, and the risk of morbidity and mortality.

Another Component of E/M Documentation

Time: In some cases, time may be the sole contributing factor in determining the level of service. Thus, the E/M guidelines speak of “recommended” time for most of the E/M encounters.  This allotted time is merely a guide. It is not necessary to use the allotted time for any particular encounter if you are coding based on the documentation of the three key components. However, in certain instances, the E/M documentation codes must include the use of “time” to determine the level of care. In such instances, the physician must spend the entire allotted time face-to-face with the patient and at least half of that time must be used for counselling and coordination of care. Moreover, the nature of counselling and coordination must also be documented.

Billing documentation for a patient visit requires the selection of the code that best represents the level of E/M service performed. This information should be effectively documented in the patient’s medical record for claims reimbursement procedures. Hence it is required for the coder to correctly understand the levels pertaining to the history, examination, and/or medical decision-making of the corresponding patient encounter, and document it correctly.

How billers and coders help with coding of E/M services?

• Analyze the coding profile: To access the coding habits, billers and coders need to create the breakdown of codes previously reported, and compare the coding patterns to the benchmark. Most computerized billing systems can produce a report that includes the data about every codes reported. Use this information in this report to calculate the E/M coding distribution.

• Analyze the list of most frequently used codes for Medicare: Coding errors performed quite frequently can prove to be more costly than rarely used codes. Hence it is important to ensure that documenting and coding these more common services are done correctly. Also, as you analyze the most frequently used codes, taking a look at the services provided by the practice but which are not billed can also help more revenue if that practice offers those services.

• Conducting a chart audit: This is one of the best methods used to uncover gaps between the codes documented and coded. Major difference between what is documented and what is coded indicates that it's time to review the E/M documentation guidelines.

• Compare your coding profile with Medicare benchmarks: This can prove to be a valuable exercise when performed regularly, along with a self-audit. It can alert you to coding trends within the practice that you might not be aware of, and it can indicate when it's time to brush up on your coding skills.

Analyzing the coding errors and correcting it in a timely manner can significantly affect the overall revenue of the practice. Due to the numerous challenges faced while E/M documentation, various practices are willing to hire medical billers and coders to take care of their coding and documentation requirements.

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Our job portal, industry updates and newsletters provide a vast pool of opportunities and knowledge to our coders; along with constant updates about industry changes like the ICD-10 transition updates through our ICD-10 training guide. Our coding specialists are constantly trained and updated about recent industry updates, hence are able to provide accurate solutions to healthcare providers across all specialties & states.