Increase Revenue & Lower Compliance Risk With These 6 E/M Tips
Selecting the right evaluation and management (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. YES HIM Consulting’s team of skilled coders and auditors are ready to provide their expertise in consulting and coding support, so contact us today for your service proposal.
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 the clinician visit is missing documentation, there is a risk that the coder may down-code the encounter.
Top E/M Tips For Your Bottom Line
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 knows the required documentation for each E/M level. A comprehensive scoring guide helps 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). 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. A multi-system exam could wrongfully inflate E/M levels. Negative findings should reflect what the physician specifically asked the patient. And 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. The latter provides different options for single system exams.
- Know how to calculate MDM. 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. As well as the amount of time 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, can identify underpayment situations in time. The organization can 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.