Part B Insider (Multispecialty) Coding Alert

7 tips to boost your E/M levels and improve documentation

Your records may have a history and physical exam as spotless as your mother's china, but if the medical decision-making is weak, auditors can come and shatter your claims to pieces.

Luckily, experts have a few suggestions to help you repair your claims' medical decision-making. Use these seven tips to make MDM documentation a breeze.

1. Ask your physician to list complicating factors. These could include comorbidities, other chronic conditions the patient may have, medications the patient is already taking or adverse reactions the patient had to previous medications, says Lori-Lynne Webb, director of coding and compliance with Saltzer Medical Group in Nampa, ID.

2. Look at the tests and medications the physicians have ordered for clues to the extra complexity the physician may not be explaining, advises Jean Keller, an auditor with Applied Medical Services in Durham, NC. Look at the history of present illness and review of systems to determine what the physician is trying to rule out, but also encourage the physician to state what diagnoses he or she hopes to rule out or confirm.

3. Ask physicians to dictate records on their level-four or -five visits instead of using a checklist or template, says Keller. Some templates don't give enough room to explain why the physician made some decisions, and often physicians won't even use the spaces provided.

4. Don't assign a level four or five just because the physician documented lots of activities. Look for a story that justifies the medical necessity of a higher level. The "pendulum is swinging back" toward medical necessity as the main criteria for judging the need for E/M services , Webb says.

5. Don't code a higher level of decision-making than the documentation supports. Often, coders will boost the MDM because they know the patients are in really bad shape, says Marcella Bucknam, HIM coordinator with Clarkson College in Omaha, NE. "They get emotionally involved in the complexity of the problem and don't code what the doctor wrote down," she explains.

6. Tell physicians they should make clear when they're taking an intermediate step that they don't believe will solve the patient's problem. For example, they may try physical therapy before resorting to surgery or antibiotics before a more aggressive treatment. Explaining that they're trying the more conservative treatment, but that the patient may require a more aggressive approach, can boost the level of MDM, says Bucknam.

7. Ask for more details if the physician writes something like, "labs reviewed," says Keller. The patient may have had an adverse reaction to something he received in the emergency room. Likewise, if the physician followed up on the patient's blood pressure, find out what was wrong with the patient's blood pressure earlier.