EM Coding Alert

Hint: Medical record notes should include both reason for encounter and plan of care.

Comprehensive documentation is key to establishing and maintaining accurate medical records for patients, as well as ensuring timely and accurate payment for providers. Payers and auditors look to providers’ notes for the details to support medical necessity, accurate and appropriate evaluation and management (E/M) service levels, and other aspects of care.

If your provider’s documentation doesn’t have enough information for you to do your job as a coder, it’s your responsibility to query them. Use these helpful guidelines for reviewing patient records and respectfully reaching out to clinicians.

Use CMS Guidelines for Proper Documentation

The Centers for Medicare & Medicaid Services (CMS) stresses that a valid claim must have sufficient documentation to verify services performed were “reasonable and necessary,” and “supports the level of service” billed. In other words, if documentation is missing or insufficient, then there is no proof the reported codes accurately represent the encounter. Furthermore, if the documentation does not support paid claims, reimbursement may be considered an overpayment, and CMS could recoup the funds if an audit included such services.

CMS dictates medical record notes should meet the following criteria:

1. Notes are complete and legible.
2. Notes include:
   • Reason for the encounter, relevant history, findings, diagnostic test results and date of service;
   • Assessment, clinical impression or diagnosis;
   • Plan of care; and
   • Date and legible identity of the observer.
3. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.
4. Past and present diagnoses are accessible to the treating and/ or consulting provider.
5. Appropriate health risk factors are identified.
6. The patient’s progress, response to and changes in treatment, and revision of diagnosis are documented.
7. The treatment and diagnosis codes, (as well as the level of care) reported are supported by the documentation.

(Source: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf).

Consult CPT^® E/M Guidelines

While CPT^® makes it clear that its E/M guidelines don’t establish the documentation requirements or standards of care, it does remind coders of the main purpose of documentation. Proper documentation is meant to “support the care of the patient by current and future health care teams,” according to the E/M Guidelines.

H&P is still important: It’s a common misconception that since history and physical exam haven’t directly contributed to code selection since 2020, there is no reason to spend time documenting the history and examination. But exams and history are very much still part of the E/M services, and therefore, must be documented. The E/M code descriptors tell you the service must include a “medically appropriate history and/or physical examination, when performed,” according to the guidelines. Remember the purpose of a complete medical record is to provide thorough information for current and future healthcare teams.

Keep These Questions in Mind for Medical Record Analysis

The quality of the provider’s documentation allows coders to not only code with accuracy, but also to the highest specificity. It’s important the provider get credit for all the work done. “When I’m analyzing a record, I like to use the acronym M.E.A.T., which stands for Monitor/Manage, Evaluate, Assess/ Address, and Treat,” explains Keisha Wilson, CCS, CPC, SPMA, CRC, CPB, AAPC Approved Instructor, at KW Advanced Consulting LLC in Brooklyn, New York.

It’s crucial to look at the patient record and see whether all of those elements have been addressed in the documentation. Ask yourself questions such as the following:

• Are there symptoms that show the progression or regression of a disease? (monitor/manage)
• What are the providers doing to evaluate this condition, and what are the tests ordered? (Evaluate)
• What tests have the patient had in the past/today? What were the findings? (Evaluate)
• How are they assessing and addressing the condition today? (Assess/Address)
• What is the plan for treatment? (Treat)

“If a provider keeps the term M.E.A.T. in mind, they will often have all the needed information for the coder to code the encounter without many queries,” Wilson says.