EM Coding Alert

Experts offer their advice for best practices.

Accurate documentation produces accurate E/M coding.

That’s the opinion of two leaders in the healthcare software industry.

But what does good documentation look like? More, what should your providers know about their documentation that will help you justify the correct level of E/M for an encounter? Following these four best practices identified by our experts will help you collaborate effectively and code the correct level of E/M service quickly and easily.

1. Specificity Is Essential

Providers must always remember that coders can’t infer details from the medical records, advises Deena Wojtkowski, CPC, CEMC, CCP, vice president of client services with ebix, Inc. “Often, I’ll be reading a note and I’ll know a doctor had to review something in order to come to a conclusion, but it isn’t documented,” she notes.

In some cases, she finds that newer physicians document thoroughly, but once they begin treating the same conditions frequently, they know the information in their heads and then fail to document the details. “I will say to them, ‘I know you’re asking these questions of patients, so please put it in the documentation — there doesn’t have to be a lot documented to meet the elements, but it has to be there.’”

This doesn’t require you to document paragraphs of text, she notes. “Being thorough doesn’t mean being overly wordy, but you’re shortchanging yourself if you don’t include the necessary elements that will allow you to report the higher codes if you actually performed what’s required of them.”

2. Don’t Let Fear of Audits Drive Undercoding

Practices should always report the level of service that’s documented, even if they think it may make them an audit target. As long as the documentation is genuine and thorough, you should report what you perform, says Henry Borkowski MD, CEO of OmniMD, a software firm that helps physicians document more thoroughly.

“I noticed a trend that there’s a tendency toward undercoding because of the fear of audits and also due to underdocumentation,” he notes. “The history of present illness is often extremely brief, and physicians underdocument — so therefore they undercode. That can have a financial impact on a practice.”

Instead, he adds, providers should be thorough in documenting, which should make them unafraid of reporting high-level codes when warranted. “Not documented, not done,” he says. “I’ve seen overcoding; I’ve seen undercoding — my goal is correct coding.”

3. Remember That You Can Bill Based on Time

In cases when the physician spends a lot of time with the patient and documents accordingly, don’t forget that you can bill based on time, Wojtkowski says. “Sometimes the patient wants to talk for 40 minutes, and the elements don’t meet the requirements for a level-five office visit (99215, Office or other outpatient visit for the evaluation and management of an established patient … Typically, 40 minutes are spent face-to-face with the patient and/or family.),” she says. “If you can prove that over 50 percent of the visit was spent counseling the patient and you have documentation about what was discussed and how much time was spent, then the other elements don’t matter and you can select the code based on time.”

The documentation should note the total time spent, the time spent on counseling/coordinating care, and what was discussed, she adds. Something like “I spent 25 minutes of this 40-minute visit counseling the patient on dietary issues that could be exacerbating her COPD and instructed her on the plan to eat six small meals rather than three big ones” would typically be sufficient to meet the current regulations for time-based billing.

4. Always Review Acuity, Comorbidities

When you’re reviewing the medical decision making in the note, “the presenting problem and acuity of the patient should be the base of the E/M level,” Wojtkowski says. This will be particularly important in 2021, when you’ll select your outpatient E/M code levels based on either time spent or the MDM.

“When I educate physicians, I tell them to think about the acuity of the patient,” Wojtkowski says. “If the doctor is prescribing a new medication and/or refilling one, you’re already at moderate in the table of risk — the key is that they document all of that,” she adds. “More tests or radiology studies ordered can push MDM to the next level, but the clarity needs to come from the provider via the documentation.”