E/M coding raises many questions for billers. Here is a selection of guidance from experts on the latest twists and turns in E/M coding.
Dont Let Your EHR, Changes in E/M Terminology or the New TCM Codes Confuse Your E/M Coding
How to Avoid 3 EHR Myths that Can Compromise Your E/M Coding
An EHR can be a helpful tool to save physicians time and ensure that documentation is thorough and neat. But there can be a downside to EHRs if you arent careful: They can mislead you into creating documentation you dont really need or that is not pertinent to the evaluation of the presenting problem(s) and in some cases, cause you to fail to document items required to support your code choices.
Consider these three EHR myths to show exactly where your EHR system could be compromising your coding:
Myth 1: Exam Documentation Will Carry Over for Follow-Up Visits
If your EHR is producing documentation that is robust in one section (such as History) and thin in another (such as the Physical Examination), you may be trusting the system to do too much.
A subscriber recently told Ob-gyn Coding Alert that an auditor down-coded most of her E/M claims due to an empty Physical Exam section in the documentation. However, the practice argued that the EHR vendor had told them that patients being seen for established problems already have physical examination documentation on file, and that the EHR will carry it over from one visit to the next.
Caution: This may be true for past medical, family, and social history (PMFSH), but not for a physical examination. In addition, as the patients condition changes, so might physical findings. A medically indicated examination due to the patients complaints must be done at each separate visit.
E/M guidelines state that if a patients PMFSH has not changed since a prior visit, your ob-gyn does not need to document the information again. He does, however, need to document that he reviewed the previous information to be sure its up to date and also note in the present encounters documentation the date of acquisition and location of the initial earlier PMFSH. Some payers will give no PMFSH credit if you overlook one of these two criteria.
Best practices: As an example, you can note in the record, I reviewed the past, family, social history with the patient taken from todays patient questionnaire and our previous visit of June 1, 2012. She reports that nothing has changed since that date. However, there is no substitute for recording your physical exam information on each visit.
Myth 2: EHRs Calculation of Time Spent Qualifies You to Code Based on Time
Many EHRs record a summary of the time spent on the record at the bottom of each visits documentation and give a total, such as Total time: 26 minutes, 15 seconds. Some practices have reported that they have used this time calculation to select an E/M code based on time alone. For example, if the EHR says that the time spent is 25 minutes, these practices are automatically reporting 99214 for the visits, using the rationale that CPT and Medicare guidelines allow you to code E/M services based on time alone.
Important: The key to billing based on time is that counseling and/or coordination of care must dominate the visit. Therefore, you can only select an E/M code using time as the controlling factor if you meet the rules, and an EHRs notation of time spent in the record will not meet those guidelines. Instead, to bill on time alone, the providers documentation must contain the following three elements:
Notation of the total time spent on the encounter,
Notation of the total time spent on counseling and/or coordination of care or the percentage of the visit spent on counseling/care coordination
The reason for/topic of the counseling/care coordination
Remember that the content of the counseling must also be in evidence in the documentation. Simply stating time in the correct format is not enough to bypass the key elements and select the E/M code based on its typical time.
Myth 3: You Should Use the EHRs Code Selection in Every Case
Your electronic health record probably offers an E/M code suggestion at the end of each visit–but that doesnt mean you should use that to justify all high-level codes.
Several practices have reported that their providers thoroughly document the History and Physical Exam elements for all conditions, leading to high-level codes, even if the medical decision-making (MDM) does not support 99214 or 99215. They justify this by pointing out that established patient office visits only require two out of three key components (History, Exam, MDM).
Important: CMS indicates in its Carriers Manual that Medical necessity is the overarching criterion for payment in addition to the individual requirements of a CPT code. In addition, the 1995 E/M Guidelines state, The documentation of each patient encounter should include: reason for the encounter and relevant history, physical examination findings and prior diagnostic test results.
Use your EHRs code selection only as a suggestion, leaving the final code choice up to the clinician, and it should be based on medical necessity and the nature of the presenting problem.
Dont Let Changes in E/M Terminology and the New TCM CodesConfuse You
Advice on applying E/M with new provider-neutral language, new TCM codes and other tips was provided by speakers at the American Medical Associations (AMA) annual CPT and RBRVS Symposium.
Most importantly, CPT 2013 has introduced two new codes for transitional care management (TCM) services:
99495 Transitional care management services with the following required elements: communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge; medical decision making of at least moderate complexity during the service period; face-to-face visit, within 14 calendar days of discharge
99496 … medical decision making of high complexity during the service period; face-to-face visit, within 7 calendar days of discharge.
Fortunately, as reported in our last newsletter, these codes can help increase revenue for primary care practices. The codes are meant to represent situations when a physician oversees an established patient whose medical/psychosocial issues require moderate to high complexity medical decision making (MDM) during the shift from a healthcare facility setting back to the patients community (home) setting. Another key to determining whether to report 99495 or 99496 hinges on timely follow-up how many days pass between the patients discharge and when the physician is able to see the patient.
Change to Non-Physician Language in Coding
The most widespread changes throughout CPT 2013 the switch to more inclusive or provider-neutral language shouldnt be difficult for most practices to put into place.
Key Change: Hundreds of codes were revised for 2013 to include provider neutral language. Codes throughout the book have replaced designations of physician with individual or qualified health care provider.
Note: A few codes retained the physician language, such as those related to skilled nursing facility admissions, because regulations require that a physician admit the patient.
CMS Providing Some Help on Vaccine-Related E/M Coding Change
Kent Moore, AAFP Getting Paid Blog
The Centers for Medicare & Medicaid Services (CMS) is providing some limited relief to physicians dealing with recent changes to how they’re paid for vaccinations.
The Jan. 1 round of Correct Coding Initiative (CCI) edits required that providers append modifier 25 to evaluation and management (E/M) services performed in connection with immunization administration services (90460-90474) provided on the same date to the same patient or only get paid for the immunization administration Read More
For more expert assistance with insuring your E/M codingand all your billingis correct, contact Medical-Billing.com at 800-966-9270. Our billing management team has more than 50 years combined experience in medical billing and coding and is ready to help you make sure you are bringing the maximum to your bottom line.