Wiki Ill Feeling/E/M Coding

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ajhunsicker

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I really need some serious input here. Been returning NP documentation to the physicians due to the MDM I feel does not meet the level of E/M they have chosen. I am getting them back with notes to charge anyway. Second if it is a Workers Comp claim where we have to attach the notes and the assessment/diagnosis or the number of x-rays taken of say the knee are not stated in the documentation I am being told by the physicians to attach the encounter/super bill because it is marked on there. I know I am fairly new at this, but is that acceptable. My stomach is churning. Also, I had told one of the physicians that afebrile is not acceptable when part of the vitals again I was told that the actual temp is in the patient EHR and can always be access for that day. Is this correct also. SO CONFUSED Thank you for listening.. AJ Unsertain
 
First of all, remember that your role is not to second guess the care they give to the patient. You do, however have the opportunity to determine whether or not the documentation (any documentation) is present and whether or not it's OK to use it for E&M levelling.

If you're sending lots of visits back, you're going to find yourself battling wits with the physicians. Make sure you are very clear on what constistutes an E&M level; and then educate them in small steps.

The billing tool (fee ticket) is not a medical record. If the information is not in the actual procedure/progress note, then they would need to ammend that progress note. Otherwise, you can't count it. You may have to code from the history components if they leave out the assessment diagnosis.

Afebrile is acceptable. It means no fever. If you have an EHR.....why are there problems with the documentation? Doesn't that data drop to the note?

Your confusion is common with E&M. I suggest you take a look at the 1995 and 1997 guidelines; and there are a number of great E&M coding guidelines out there. I recommend two books; Practical E&M by Steven Levinson, MD (he looks at E&M from the point of view of the EHR), and Optum has an E&M coding guide that's very helpful.

Any of the AAPC webinars or workshops that offer E&M education should be on the top of your to-do list. Check your local chapters to see if anyone is offering an E&M presentation. If you're going to be auditing physician E&M, you have to wrap your head around this and be confident that you're giving them the best support and advice. What you don't want is to be so anxious and unsure about this that your providers doubt your ability. Good luck.
 
Thank you so much for you input I greatly appreciate it. As for the EHR and documentation, the physicians do not always update correctly for each visit and I have explained this to them also. The diagnosis in the documentation is not the same as that in EHR data note. Sometimes completely different. Told them many times it needs to be changed/updated each visit. What to do.? I just feel sometimes like I am banging my head against a wall. Do other coders feel the same way.?
 
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