Welcome back to our two-part series on Coding E/M Services. As we covered in part one of this series, the level of E/M service determines the payment for the visit an there are seven components that factor into the E/M Service. The first three we reviewed are the chief complaint, history and examination. Below are the other four.
Medical decision-making (MDM) is probably one of the trickiest to gauge because it is based on the number and types of medical problems addressed, the complexity of establishing a diagnosis and the decisions made by the clinician in the management of the conditions. MDM ranges from straight-forward to complex (low, moderate or high), and each of these requires meeting certain criteria explained in the E/M codes’ documentation guidelines. It is a critical mistake to believe that listing all or many of the patient’s chronic diagnoses – in what we refer to as a laundry list – is sufficient to support highly complex MDM; it does not. The MDM stems from the complete history, exam and assessment of all of those conditions as documented in the note. That’s the tricky part because it requires synthesizing onto the screen (or page??) all the relevant considerations in the mind of the clinician when evaluating the patient.
Counseling and coordination of care are usually reported in the same areas of the progress note. In these sections, the provider summarizes the next treatment steps for the patient’s conditions and explains the counseling (or instructions) given to the patient. Many providers rely on templated language (a topic explored in this blog) for counseling on diet, exercise and other lifestyle habits and/or list handouts given to the patient on specific diseases. Not only do these activities barely scratch the surface in this regard (as we will see in the last component of the E/M service) but they sometimes contain phrases that are not true for the patient.
Time is the last element that may affect selection and support of an E/M code. If more than 50% of the visit involves counseling and/or coordination of care, the amount of time spent in these activities could justify a higher code level. However, keep in mind that illness complexity does not drive the time factor. The keys to taking advantage of the time element are: the time spent in counseling must be listed on the note and the documentation must explain the counseling given to the patient, not just providing a handout.
Templated language makes it easy for providers to document “counseling.” If the information isn’t completely verbalized to the patient, some prevailing considerations might be that the patient will receive a copy of the visit note and thereby “be counseled.” We strongly caution clients against that approach. An interesting study we summarized from JAMA revealed that more than 20% of patients found errors in their medical notes, and some specifically cited areas, such as counseling, that were documented by the clinician but were not performed.
Fortunately, many providers employ coders in their practices who can review the documentation and make sure the selected codes are correct, while others may outsource their coding to a firm specializing in this area. A mechanism for provider education and feedback is important in order to minimize future errors in E/M coding since let’s face it, clinicians are now forced to wear a coder’s hat but haven’t really been educated on the nuances of proper coding. If you would like to explore outsourcing your practice’s coding, or would like education for your clinical or coding team, please contact us.