E&M Coding and Documentation: CDI and Physician Buy-in

Eight key guidelines for ensuring proper coding.

EDITOR’S NOTE: The following is a summary of a presentation by Margaret Skurka during the 2017 American Health Information Management Association (AHIMA) national convention in Los Angeles.

Evaluation and management (E&M) documentation principles have been around a long time – since 1995, in fact. Consider the 1995 and the 1997 Guidelines from the Centers for Medicare & Medicaid Services (CMS), which have not been updated since. There is still some varying interpretation of the Guidelines in physician practices and hospitals nationwide.

Here are eight takeaway principles to help in the selection of the correct code:

1. Medical necessity has many definitions. Correct documentation is of the utmost importance for the selection of the correct evaluation and management (E&M) service. It is not medically necessary or appropriate to bill a higher level of E&M service when a lower level of service is warranted. The volume of documentation is not the correct or primary criteria when selecting a code. Rather, the documentation needs to support the level of service reported.

   Based on the medical necessity, a provider should take an appropriate history, document the exam, order appropriate diagnostics, and document the complexity and the time spent face-to-face with the patient for the office visit. If the visit does not necessitate the detail to code at a 99214, for example, a lower level should be used. Payers such as CMS, the Comprehensive Error Rate Testing (CERT), the Recovery Audit Contractors (RACs), the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), and private insurers are paying attention.

2. The four worst problem areas in electronic health records (EHRs) include auto-population of fields, counting repeat work, cloned notes, and Level 4 and 5 visits. 

   Don’t auto-populate the ROS, the past, family, and social history, and of course, the physical exam – this can only lead to disaster if not updated for each visit. The provider looks bad, as does the entire operation.

3. Make sure for any consultations, that you meet the three R’s: there is a request for the provider to see the patient, there is a review of the patient with appropriate documentation, and then a report back to the requesting physician of the findings. Medicare does not pay for consults, and has not since 2010. So, for these patients, you are reporting new, established, initial hospital, or subsequent hospital care, or ER visits – anything but a consultation code. An ER code can be reported if the consultation service was provided in the ER and the patient was discharged. If the Medicare patient is admitted after receiving services in the ER, the initial hospital care code should be provided.
4. Choosing an E&M code requires the appropriate level of history, the appropriate level of exam, and the medical decision-making. Remember that it is harder to bill higher on new patients and consultations, as all three levels of criteria must be met. On established patients, two of three criteria are required. Time is used if appropriate and documented.
5. Continually evaluate your E&M utilization. Are you an audit target? Does the graph of your provider exceed the Level 4s and 5s reported in your state? Or at the national level? Or for your specialty, at either the state or national level? This spells trouble, for sure. Run your practice data monthly, quarterly, and yearly, and compare them with similar groups. Identify providers in your group that stand out because of aberrant data. Be proactive here.
6. Decide which E&M guidelines are best for your practice – the 1995 or 1997 version. Then design your EHR to capture the required items for those guidelines. If physicians receive prompts about the inclusion of various organ systems or body areas as they are completing the physical exam, the practice is more likely to capture requisite data. Have the body mass index (BMI) automatically computed to prompt, if appropriate, a diagnosis of obesity or morbid obesity.
7. Educate your providers often on needed clinical documentation. Have good query templates for common conditions such as anemias, sepsis or septic shock, CHF, renal failure, pneumonias, and altered mental status on the diagnosis side. Do the same for common issues in PCS on the hospital side, in terms of approaches and devices used. Coders love complete documentation. Ask for clear documentations for present-on-admission conditions versus hospital-acquired conditions, and make sure the path report findings are acknowledged in the record.
8. Bring it all together: quality documentation and correct selection of the level of history, examination, and medical decision-making. Enjoy knowing that your documentation is sound and correct and can withstand scrutiny. And know that all of this is the correct data quality that we strive for, resulting in quality patient care. That’s the bottom line. Those of us in the business side of healthcare know that quality data is the cornerstone for all the rest.

So follow these basic principles as you work with your providers to help capture the necessary documentation to support the code(s) you are using. Documentation needs to support whatever code is chosen. That is the most important takeaway point! Do it correctly, and appropriate revenue will follow.