EM Coding Alert

Example: A patient presents for a simple ear flush for cerumen removal. The patient has a recurring appointment for this procedure. On this visit, the patient says, “My ears are clogged again, but I noticed my ears are red and I have a fever.”

“The cerumen removal is the procedure. There’s no E/M there,” said Lehrman. But now there’s a new development in the form of a possible infection, something significant and separate from the procedure. “Now, we ask questions and document how long they’ve been experiencing the problem, what makes it better and what makes it worse, what treatments are available, what has the patient tried already, has the patient experienced this before. Then we diagnose cellulitis, and we manage it with an anti-infectious agent,” he explains. Without a paragraph in the notes describing the evaluation and the management of the new problem, there’s no documentation that an E/M service occurred along with the cerumen removal. On paper, it looks like the procedure was the only billable service provided.

Don’t Equate H&P With E/M

In any encounter, history and physical examination (H&P) is just evaluation. “What’s missing from the H&P when comparing it to any E/M is the ‘M’ part, the management,” Lehrman said. “Management is the provider using their education and expertise and training to somehow manage that problem. That is work,” he continues.

What defines a significant and separately identifiable E/M service is the existence of an E/M service and a procedural service that don’t overlap in the work needed to complete either one, according to Chapter 1 of the National Correct Coding Initiative [NCCI] Policy Manual for Medicare services. “We can have work devoted to the E/M where there is no overlap with the work needed to perform the procedure, but the documentation must support that. That’s a key area where we see providers getting into trouble,” Lehrman said.

Example: A new patient comes in on referral to receive a steroid injection of a joint. The provider wants to submit a new patient E/M with the procedure. The lengthy note outlines the chief complaint, as well as a full history and exam, but the treatment section just outlines the procedure. The patient is new, and extensive notes were taken, but neither of those things warrants an E/M code on their own. This is especially true now that each of the office/outpatient E/M service requires a certain level of medical decision making in addition to a medically appropriate history and/or examination (unless coded on the basis of time).

“Attention was directed, the needle was stuck in, the product was injected. That’s all procedure. The work of the management portion of the E/M is missing. That note could be eight pages long, but the third-party payer is looking for the work associated with the E/M,” explained Lehrman.

Don’t Use E/M for Every New Patient Scenario

A new patient encounter with a procedure usually warrants the submission of an E/M, but nothing is automatic without documentation to back it up.

In fact, “Medicare global surgery rules generally prevent the reporting of a separate E/M service for the work associated with the decision to perform a minor surgical procedure regardless of whether the patient is a new or established patient … The fact that the patient is ‘new’ to the provider/supplier is not sufficient alone to justify reporting an E/M service on the same date of service as a minor surgical procedure,” according to the NCCI manual. Though NCCI is technically a Medicare program, many third-party payers consider Medicare rules to be a reasonable standard. “I suggest this as a good rule to normally apply to all,” said Lehrman.

These rules hold true for nonsurgical establishments and encounters, as well as preventative services. Just because the procedure isn’t surgical, doesn’t mean anything changes.

Example: A new 19-year-old patient had been seeing a pediatrician, aged out, and was referred for immunizations required by school. Vaccines were prepared, locations were sterilized, and vaccines were administered. The patient also has anxiety. Anti-anxiety medication was prescribed.

The provider probably did a full E/M before prescribing the anti-anxiety medication. However, unless the provider’s documentation describes the evaluation (for example, medically appropriate history and/or physical exam) and management (for example, medical decision making [MDM]) that occurred, there is nothing to say an E/M service took place. If there is no evaluation or no management in the notes, it’s not just going to raise a red flag to an auditor, it also will be almost impossible to assign an accurate E/M code. “With the 2021 E/M guidelines for MDM, details … are important in order to provide an accurate level and maximum possible revenue,” explains Chelle Johnson, CPMA, CPC, CPCO, CPPM, CEMC, AAPC Fellow, billing/credentialing/auditing/coding coordinator at County of Stanislaus Health Services Agency in Modesto, California.