Increase Revenue & Lower Compliance Risk With These 6 E/M Tips
Selecting the right E/M code can be tricky – and sometimes, costly – business. On the one hand, the coder does not want to choose a diagnosis that’s too high, which could potentially incur audits or claims denials. But, if the coder selects a code that’s too low, there’s a chance of losing revenue for his or her organization.
According to Medical Economics, “payers and auditors use a quantitative scoring process that requires specific elements (i.e., history, exam, and medical decision-making [MDM] – or time spent counseling and coordinating care) for each E/M level” (2020). If each element of the clinician visit is not correctly documented, there is a risk that the coder may down-code the encounter.
Here are some tips, generated from Medical Economics, to help coders and auditors efficiently code E/M visits that will increase revenue and decrease compliance risks (2020):
- Develop a process to ensure quality E/M documentation. Make sure the coder is aware of what documentation is needed for each E/M level. A comprehensive scoring guide will help coders determine if those requirements are met, narrowing down the correct code level. For reference, review the guide to E/M codes from Family Practice Management (FPM) journal (2011), and refer to the coding reference cards gathered by the American Academy of Family Physicians (2019). The American Medical Association (AMA) offers additional E/M coding tips, as well as procedures for incorporating guideline changes into a practice or clinic.
- Document past medical history. For Level 4 or 5 new patient E/M code, several items need to be documented, including “one specific item from the past medical history (i.e., illness, operations, injuries, treatments, medications, or allergies), one specific item from the family history (i.e., medical events or hereditary diseases that place the patient at risk), and one item from the social history (e.g., use of tobacco, drugs, or alcohol)” (Medical Economics, 2020). In the history of present illness (HPI) section, an analysis of the body systems that relate to the problem needs to be documented.
- Exams should only review the necessary bodily systems and areas that directly influence the medical decision-making for the current encounter. E/M levels could be wrongfully inflated if a multi-system exam is conducted. Negative findings should reflect what the physician specifically asked the patient, how they responded, and how this contributed to the evaluation. It is imperative to distinguish which E/M guideline – 1995 or 1997 – the organization’s Medicare Administrative Contractor (MAC) uses, as the latter provides different options for single system exams.
- Be knowledgeable about how MDM is calculated. The MDM includes “the number of diagnoses and management options considered, the amount and/or complexity of data reviewed (e.g., urinalysis, EKG, lab results, or additional workup planned), and the risk of complications, morbidity, or mortality” (Medical Economics, 2020).
- Record the amount of time spent during the visit. Report the total amount of time the physician spent with the patient and his/her family, how much time was used to counsel on care, and the summarized details of the conversation.
- Be vigilant for underpayments. Small errors in documentation or E/M calculations can lead to under-coding, which ultimately causes loss of revenue. Luckily, a coding and auditing firm, such as YES HIM Consulting, is well-equipped to identify underpayment situations in time for the organization to resubmit the corrected claims and recoup some lost revenue. In a previous article, YES discusses how to select the right coding audit company for your organization.