Wiki E/M query

[daedolos]

I just recently took a coding exam for a prospective employer and one of the questions were as follows:




The level of E/M is based on:

A) Documentation
B) Key components
C) Contributing factors
D) All of the above

I chose the wrong answer of A. Any thoughts? I read up on E/M principles and the key driver was always described as documentation because "if it wasn't documented, it didn't happen."

Peace
@_*

 

[csperoni]

I would chose D. I get your logic that you can't bill for it if it's not documented, but the reverse it not true. Just because it is documented doesn't mean you can or should bill for it. If an established patient comes in for a paper cut and the documentation meets 99215 because the history and exam are comprehensive, doesn't mean it should be billed that way. Documentation is one piece of the puzzle.

 

[Shalinda]

I would have picked D. Documentation is important but is only 1 part of coding E/M visits.

 

[daedolos]

I would have picked D. Documentation is important but is only 1 part of coding E/M visits.

Would you please elucidate on what key components and contributing factors would be then?

Peace
?_?
I don't recall that specific terminology.

 

[csperoni]

The 3 key components of E&M are:
-History
-Exam
-Medical decision making
I feel like that is pretty basic information for a coder to know.

Contributory factors are the other items that can come into play when determining the level - time spent, counseling, co-ordination of care & nature of the illness.

All of the items can be used together, or sometimes individually to help determine a level of service.
Here's an example:
A cancer patient returns to the oncologist to discuss a recurrence, and whether a new treatment regimen, hospice, or a clinical trial will be the care plan moving forward. In a situation like this, the physician may do no exam (or a very limited exam), might not discuss/document history that is already established and known, but might spend 45 minutes talking to the patient and family in the office. Lets say it was a problem focused history, problem focused exam, and high medical decision making. So yes, of course the note needs to exist (documentation, choice A). The key components (choice B) lead to 99212 since the exam and history are problem focused. However, the time spent and counseling (option C contributory factors) lead to 99215. As long as the physician properly documents face to face time and > 50% spent counseling, you may bill 99215. In this case, you used A & C.

Further elaboration of my paper cut example:
Patient comes in for a paper cut. No infection, pt doesn't have a bleeding disorder, just a standard paper cut. The treatment is a bandaid. The physician documents a complete ROS and complete personal, family & medical history. Exam is detailed (5 organ systems examined). Medical decision making is straightforward. Again, of course the note exists (documentation, choice A). You get a 99214 from history & exam (key components, choice B). Contributory factors (choice C) lead more toward a 99212. Just because a 99214 is what is documented on the paper does not mean that is what should be billed in this case. This should be 99212 because the nature of the presenting problem is an everyday paper cut and all the doctor did was apply a bandaid.

So while documentation is required, it is not the ONLY factor in determining E&M level. Depending on the specialty you code for, and how the physician treats and documents, you may typically use key components, typically use contributory factors, or use a mix.