Pulmonology Coding Alert

Are EHR templates hurting more than helping?

The evaluation and management (E/M) code section of the CPT^® code set can be a maze of code options, rules to know, and guidelines to follow. We asked coding experts to share suggestions on how to navigate E/M coding to help your experience go smoothly.

Tip 1: Make Notes That Work for You

E/M codes have the potential to trip up the most seasoned coders, and sifting through the descriptors to find the correct code takes time. One way to improve your efficiency while searching for codes is to write in your code book. “I am a huge proponent of making notes in your coding books. Using systems like the bubble, highlight, annotate technique system (BHAT) or whatever works best for the individual coder can be very beneficial,” says Linda Martien, COC, CPC, CPMA, CRC, of Medical Revenue Cycle Management Consulting.

The office and outpatient E/M codes for new patients (99202- 99205) have similar descriptors, but one difference among the four codes is the amount of time the provider spent with the patient. “I recommend highlighting differences between code descriptors so they will ‘jump out’ at you,” says Nancy Clark, CPC, COC, CPMA, COPC, CPC-I, AAPC Fellow, senior manager of EisnerAmper Advisory Group in Iselin, New Jersey.

Many of the E/M codes have highly detailed criteria that can be hard to quickly pick out. For example, the bolded portions of the descriptors in the codes below show the detailed criteria that can easily be missed in your code search:

• 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.)
• 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.)
• 99490 (Chronic care management services with the following required elements: multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, chronic conditions that place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline, comprehensive care plan established, implemented, revised, or monitored; first 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month.)

If you can make these and other differences easier to see when turning the pages of your code book, you’ll be able to quickly find the right code for the visit you’re reporting.

Tip 2: Double-Check the Efficiency of Templates

Templates in electronic health records (EHRs) may help save time, but they can also create issues for some practices. “Many EHR templates were designed in part to assist providers in efficiently documenting the medical record. However, some of the templates do not appear to be correlated with a providers’ clinical intuition and tend to hinder productivity,” Clark says.

Pre-built templates contain mandatory fields of text that should be deleted if the provider is adding their own information about the patient’s history of present illness (HPI), family history, or symptoms the patient is presenting. As an auditor, Clark has discovered contradictions in medical record documentation that appear to be the result of conflicts between free text and the mandatory fields.

She also noticed EHR errors during the shift to the 2021 Office and Outpatient Guidelines, which are focused on medical decision making. Updating the EHR templates for E/M visits to suit these guidelines is difficult since fulfilling the requirements for E/M visits is a more clinically intuitive process for providers.

Is help on the way? “The providers I work with find that one or two education sessions and periodic coding reviews help solidify their comprehension of the guidelines and facilitate implementation to their documentation,” Clark adds.

Suggestion: If you find contradictions in the documentation that may be due to the EHR template and the provider’s free text entry, you can query the provider to ensure the information is accurate. This extra step to correct any incorrect information could help the practice avoid a denial or an audit.

Tip 3: Know How to Report Telehealth Visits

Telehealth visits exploded in use during the public health emergency (PHE), so making sure your provider properly documents that type of E/M visit is important to ensuring proper reimbursement. The outpatient E/M codes for new and established patients, 99202-99205 (Office or other outpatient visit for the evaluation and management of a new patient, …) and 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient, …), respectively, all feature a Telemed Code icon in the CPT^® code set, meaning you can append modifier 95 (Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System) to report real-time telemedicine services. So what information in the provider’s documentation indicates a telehealth visit?

Ideally, the physician or other provider would call out in the documentation that they performed a telehealth visit with the patient. “I would expect to see a date and time of the call or video encounter as well as other verbiage that would clue the coder to the type of encounter,” Martien says. The requirements for a telehealth visit may vary by payer, so you should review your individual payer preferences to ensure the documentation meets the payer’s requirements.

Factors that are commonly required in the documentation include:

• Platform or communication method;
• Patient consent; and
• Time spent.

Your physician’s documentation should include whether they used a telephone, secure two-way audio/video connection, or a telehealth platform. The documentation should also indicate the patient has agreed to receive services via telehealth. Time should be noted, too. For 99202-99215 provided by video, you have the option to bill based on time or MDM, but if your payer requires telephone E/M codes (99441-99443) to be used for phone-only services, you can report the appropriate code based only on time.

“Other indications may be present, such as provider or patient location, which was required prior to the current documentation leniencies due to the public health emergency (PHE),” Clark says.

Be sure to check individual payer policies regarding codes, modifiers, and place of service codes before reporting telemedicine services.