EM Coding Alert

Templates, guidelines, and remote monitoring top E/M challenges say experts.

No matter what your specialty, and no matter what your experience level, E/M coding always seems to create new challenges at every turn. Here are three of the biggest, according to one expert coder, along with some great suggestions for overcoming them.

1. Ensure That Templates Aren’t Creating Issues

Although having templates in your electronic health records (EHRs) can help save time, they can also create issues for many providers, says Nancy Clark, CPC, COC, CPB, CPMA, CPC-I, COPC, senior manager in the Healthcare Services Group at EisnerAmper in Iselin, New Jersey.

“In the outpatient setting, the biggest error I see is overuse of EHR templating that results in contradictions to the medical record,” Clark says. “When we incorporate templates, the goal is to ensure that the medical record is complete and includes appropriate documentation criteria. Unfortunately, I see too many templates including prefabricated responses, and the subsequent addition of free text by the provider sometimes contradicts what’s in the template,” she says.

For instance, Clark has seen EHRs that have the review of systems (ROS) pre-templated to be complete, with 10 or more systems addressed for all patients. However, in some documentation, the physician will fail to delete that pre-templated response and will indicate that something in the ROS was actually addressed differently.

“I once did a chart review where the medical record had an ROS response under the musculoskeletal section that said, ‘patient denies joint/ muscle pain,’ but in the history of present illness, the provider had written ‘patient complains of knee pain.’ So that clearly indicated the provider either did not personally take the ROS or didn’t review the documentation in the patient’s chart and signed off on a contradictory medical record,” Clark said. “In this type of situation, as an auditor, I have to question the validity of the record. I’d hesitate to credit that provider with a complete ROS when they clearly didn’t review at least part of the ROS.”

2. Write in Your Code Book to Remember the Regs

You should always be reading the introductory notes the precede the E/M codes in your code books, because they typically provide a lot of important information that can guide your code choices, says Lynn C. Schoeler, CPC, COC, CPC-I of L S Coding & Education in Tucson, Arizona.

“A lot of people skip over the introductory notes in CPT^® and go straight to the code descriptions, but you shouldn’t,” Schoeler says. “The first thing I teach coders is to write directly in the CPT^® book.”

For instance, she advises, if a code is on page 25 but the regulations for reporting it are on page 23, coders should put “p 23 paragraph 2” next to the code so they know where to find the regulations. Every year when a new code book comes out, she suggests going through it and marking it up, so you don’t miss any important guidelines. You should also check Medicare documentation guidelines to identify any discrepancies with CPT^®, and you can document those in your code book as well.

For instance, prior to the initial observation care codes, CPT^® reminds coders that when observation status is initiated in another site of service such as the ED, “all evaluation and management services provided by the supervising physician or other qualified heath care professional in conjunction with initiating ‘observation status’ are considered part of the initial observation care when performed on the same date.” That’s an important distinction to know for EDs, which frequently provide these services, and would be important to highlight directly in your code book.

3. Don’t Forget Remote Evaluation Services

Some physicians could be losing money on their visits by not recording enough documentation to justify reporting telehealth codes appropriately. “I see a lot of telehealth visits either billed but not documented appropriately, or not billed due to concerns of inappropriate documentation,” Clark said. “In 2018, CMS started to expand reimbursement for remote services — some services are simply E/Ms, but also covered are phone calls, audio visual interactions, and online interactions. With the expansion of telehealth use and the current temporary waivers that most carriers are allowing, I’d like to see practices open remote services to include more frequent patient encounters.”

She recommends that staff members review remote patient monitoring services, and notes that state parity laws exist in 42 states plus Washington, DC, which provide reimbursement of these services.

For instance, you might consider using codes from the ranges 99453-99454 (Remote monitoring of physiologic parameter(s) (eg, weight, blood pressure, pulse oximetry, respiratory flow rate), initial …) and 99457-+99458 (Remote physiologic monitoring treatment management services, clinical staff/ physician/other qualified health care professional time in a calendar month requiring interactive communication with the patient/caregiver during the month …), in addition to code 99091 (Collection and interpretation of physiologic data (eg, ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time, each 30 days). Of note, the code description specifies only one provider may report this code in the stated 30-day period, so if a primary care physician is also providing that care, it should not be reported by the emergency physician also.

Note that remote glucose monitoring is reported with CPT^® codes 95249-95250 (Ambulatory continuous glucose monitoring of interstitial tissue fluid via a subcutaneous sensor for a minimum of 72 hours…), Clark adds.