Internal Medicine Coding Alert

Strike a balance between bean counting and example-driven coding.

After circling relevant items on chart worksheet after chart worksheet, you might feel like scrapping those aids for CPT's clinical examples. Before you do so, consider these level-gathering time savers.

Let clinical examples be your guide, according to suggestions from the AMA.

"They are intended to serve as a tool to assist physicians in their understanding of the E/M codes and to guide them in determining appropriate E/M code levels," according to CPT Assistant's "Coding Communication" on E/M documentation guidelines (November 2008).

While that advice can seem like a time-saver as compared to using an audit worksheet, the method isn't practical. "The number of clinical examples needed to adequately convey the message of the E/M documentation requirements would be far too vast to be effective," says Suzan Berman (Hvizdash), CPC, CEMC, CEDC, senior manager of coding and compliance with the UPMC departments of Surgery and Anesthesiology.

Since leveling visits using only CPT's clinical examples is not feasible, consider using a tool, such as the Marshfield Clinic Tool (www.mrsiinc.com/MarshfieldAuditSheet.pdf).

Hvizdash uses a variation of the tool, which she usually finds "an easy way to explore the documentation." The Marshfield Clinic Tool helps offices develop templates, forms, and EMRs that outline documentation requirements. "When medical necessity has been met, the documentation will support the level of service billed," Hvizdash says.

Medical necessity is the key to E/M levels; check out this from the Medicare Carriers Manual 100-04, Chapter 12, Section30.6.1:

"Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted.

"The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported."

The AMA, however, stresses that CPT and CMS guidelines are not the same. "CMS used the template found in the E/M codes published by the AMA as the basis for the documentation guidelines," states CPT Assistant (Vol. 18, Issue 11, page 4).

CMS indicated how the various elements used to determine the level of history should be documented for a specific level of history described in an E/M code. "The documentation guidelines address the examination and then the medical decision making, in the same sequence as found in the E/M codes.

"Although history and examination may rely on a 'point system,' medical decision making level determination is less specified," CPT Assistant states.