Few things cause as much provider confusion – even frustration and angst – than medical coding. But coding is intricately linked to payment so the importance of doing it correctly has significant repercussions. The Centers for Medicare and Medicaid Services (CMS) commissions random audits each year in its quest to find overpaid claims or those paid in error. The 2019 results show a national error rate of 7.3%. While that may not sound like a large number, the associated improper payments are projected to be $28.9 billion. With a B!
Over $1B of the improper payments in 2019 were for established patient office visits, and another $400,000 for new patient office visits. The errors in evaluation and management (E/M) services include over- and under-coding, which are two sides of the mistake coin. E/M services include office visits for new patients and established patients. The five levels of codes for each patient category are differentiated by their complexity, which is reflected by various documented factors. Over-coding occurs when providers select a higher level office visit code than what was warranted by the documented summary of the visit; over-coding also results in higher payments to providers because the payments correlate to visit complexity. Under-coding occurs when the provider selects a lesser complex visit level code than what is supported by the visit summary. Under-coding results in a lower payment, and many providers believe that under-coding keeps them under CMS’s radar. This is not true.
The complete guidelines for documenting E/M visits can be found in the 1995 or 1997 Documentation Guidelines for Evaluation and Management Services, depending on which one your practice uses. Remember that your practice must select one set of guidelines and use them solely and consistently.
Here – in two parts – is a brief overview of E/M codes.
There are seven key components of an E/M service, and the first one we’ll review is the patient’s chief complaint (CC) or reason for the visit, which is the biggest support of medical necessity. The CC is usually in the patient’s words, but this is not a requirement as long as there is a statement that supports why the patient is having a medical visit. A CC that reads “follow up” is not correct and also doesn’t support medical necessity. A better CC would be “follow up of diabetes after my medication change.”
The history (formerly called history of present illness or HPI) should be a short narrative about all the conditions being assessed at the visit, and briefly summarize the course of the condition(s). This will further solidify the medical necessity of the visit and convey the complexity of the patient’s condition. Histories, which include the Review of Systems (ROS) and pertinent Past, Family & Social History (PFSH), are usually either brief or extended, and this distinction factors into the E/M code selection.
The CC will guide the breadth of the provider’s examination of the patient, the next element in E/M coding. Exams range from problem-focused – in the case of a visit devoted solely to the CC – to expanded problem-focused, detailed and comprehensive. The differences among these examinations has to do with the number of organ systems reviewed and the number of elements assessed for each system. Providers should be alert for exams that don’t match the CC. For example, if the patient has a cold, a prostate exam wouldn’t be considered medically necessary under the circumstances, although it may seem to justify a higher level visit.
This blog continues here.
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