EM Coding Alert

Get tips on how and when to query.

For many coders, the evaluation and management (E/M) coding updates from 2021 are quite familiar. When the inpatient guidelines caught up in 2023, some coders and physicians were left confused.

Industry insiders performed audits and case studies to help find the comprehension holes. These insights offered a picture of what coders find challenging about the 2023 E/M changes. During her HEALTHCON 2024 presentation, “Unveiling the Impact of 2023 E/M Changes,” Lori A. Cox, MBA, CPC, CPMA, CPC-I, CEMC, CGSC, CHONC, Director of Client Engagement at AAPC Services, out of New London, Missouri, shared some of those challenges along with some solutions you can take back to your office.

Challenge 1: Habits are Hard to Break

A habit is a physical and psychological phenomenon, and it’s simply not easy to break, especially in the fast-paced healthcare setting. Coders are trained to keep up with the changes, and it’s difficult enough to truly stay on top of all the changes. It’s even more difficult for physicians. After all, they spent many years focusing on the quantity of the documentation, and now the focus is more on quality. If a physician is accustomed to documenting just all the areas they examined on the body but fails to document the thought processes behind the tests, potential diagnoses, risks associated with the condition and its management, it’s not likely the payer will reimburse at the desired level.

Challenge 2: Documentation Gaps

One thing experts are noticing is that while accuracy percentages are increasing, there are still many practices who are habitually under-coding or over-coding. Some doctors are under-coding due to confusion and fear of the repercussions of over-coding. Other doctors are over-coding because they are either following outdated guidelines or their documentation is incomplete. Here are common areas where providers’ notes could use more detail, which will enable you to assign the most appropriate E/M level for the encounter.

Severity of risk: Severity of risk is hard to assess when the documentation is lacking in detail or direct language. “If a high-risk patient decides to stop treatment, they may still be high risk. What other treatment options are available and were discussed? These things need to be documented,” said Cox.

Status of conditions: The documentation needs to include the status of relevant conditions. “If the patient has no complaints with their diabetes, are they actually stable, or do they just have no complaints? What if those patients’ lab results show they aren’t stable? What is the actual status of the condition?” asked Cox.

Data elements: “The patient continues with their medication. Okay, do we really count that as moderate? There has to be a change or the physician has to otherwise address the medications in order for it to qualify as a moderate risk,” Cox said.

Differential diagnoses: Physicians routinely leave out their thought processes and clinical reasoning. The complexity of medical decision making (MDM) often depends on this thought-process, however. Aside from helping future healthcare professionals and enhancing patient care, a well-documented differential diagnosis can easily demonstrate a higher level of complexity.

Challenge 3: Lack of Understanding of How Things Relate to MDM

A lack of detailed documentation often stems from a lack of general understanding. Providers don’t always know the importance of documenting the nature of the problem or the risk, and the coders can’t interpret vague notes. “I wasn’t in the room when the doctor saw the patient … you’ve got to explain it to me,” Cox continued.

Nature of the presenting problem: Why is the patient seeing the healthcare provider? This is crucial in MDM because it guides the provider toward further examinations, ordering of tests, and determining possible diagnoses.

Risk: “Risk is specific to the patient on that day. For example, a normal, healthy patient with a sinus infection likely indicates low risk. However, if we have an elderly patient or an HIV patient with several comorbidities, that sinus infection is now presenting a higher risk. A homeless patient isn’t going to be taking great care of themselves, so they “sometimes get to moderate or high risk just because they have those social determinants of health [SDoH],” said Cox.

Data: The data element of the MDM table is tricky, even for experienced coders. Data is nebulous, but these are a few areas physicians routinely fail to document:

Who is there? This baby isn’t talking to you about her ailments. Explain who is in the room because that counts as an independent historian. That counts toward data.

There is a difference between review and interpretation. Did you independently interpret something? If so, that counts toward data. It doesn’t count if you just looked at a fracture or a meniscus tear, but explain what was in the report. That counts toward data.

Challenge 4: Time

Total time can be tough because a lot of providers don’t document times. We want to use Time or MDM, depending on which one is higher. The provider should get the reimbursement they deserve, after all. However, some electronic systems will automatically adjust the level depending on what time is noted, which can lead to incorrect coding.

When you’re dealing with separately reportable procedures, such as X-rays, the independent interpretation of that can’t be counted as total time. It’s often not clear in the note however. Vague notes such as “spent more than 20 minutes with the patient” aren’t good enough either. Nor will it suffice to mark down 30 minutes for every single patient.

Understand How to Solve These Challenges

Knowing the specific areas that are generally problematic is helpful, but what can be done to improve processes and outcomes?

Reassess compliance program: Having a solid compliance plan is great, but it’s no good if support doesn’t come from the very top. Solid teamwork at all levels is the key to a stronger compliance audit foundation. Educate, audit, reaudit, then revise training programs if numbers aren’t improving. This kind of organization and proactive action is often required.

Perfect physician queries: Coders and physicians don’t speak the same language. Coders know the shorthand for their coding world, and doctors know the shorthand for theirs. This breakdown in communication is often because coders and doctors have trouble meeting in the middle.

• Know when to query:
  ○ Is there conflicting information?
  ○ Are there statements without clear support of evidence?
  ○ Is there illegible or incomplete documentation having to do with the reason for the visit, acuity of the patient, risk of management or treatment, reason for tests or the visit?
• Know how to query:
  ○ Write the question down
  ○ Be clear and concise
  ○ Include clinical indicators from the record
  ○ Present only the facts which identify why clarification is needed (without leading the physician)
  ○ Be sure to not include the impact on reimbursement
  ○ Be compliant with practice guidelines
  ○ Be respectful
  ○ Include yes/no questions whenever appropriate

Lara Kline, AS, BS, Development Editor I