E/M DOCUMENTATION Does Your Coding Match Your Documentation???

by  Marge McQuade, CMSCS CHCI CPOM
Dec 12th, 2017

No matter what your specialty we are all faced with making sure our physician uses the correct E& M Code for what he/she documented.  Remember if it wasn’t documented it wasn’t done!!!! That said, when looking at documentation to code E/M services, it’s good to educate the providers to document in a manner that clearly identifies the service provided.  To make sure that your provider’s documentation is consistent and to make that happen setting up some internal policies and procedures for documentation or using templates will be helpful.

The most important aspect of E/M documentation is that the complete clinical picture appears in the medical record.  One way is to get your physician to embrace the SOAP (subjective, objective, assessment, plan) format  The subjective element is the patient’s account of the problem he or she is being seen for.  The objective element is the lab work or other undisputable findings. The assessment is the physician’s professional opinion of the problem. The plan is the treatment for the problem. The key components of E/M coding which are history, physical examination and medical decision making correlate to the SOAP format. There can be a wide discrepancy when the same documentation is reviewed by several different coders or even physicians or auditors.

From a coder’s perspective one of the most difficult instincts is the desire to assume missing information in the medical record to justify a code selection and with “interpretation” of guidelines being sometimes an individual choice that can be dangerous.   A coder should never fill-in, take out or assume that elements belong in the medical record if they are not there.  Each E/M code should be evaluated on the documentation only.  Referring to information obtained from a prior history or exam is unacceptable grounds to make code assignments.  

It is also important to make sure that you are consistent with using either the 1997 guidelines or the 1995 guidelines.  

If a progress note doesn't reflect the number of "bullets" (1997 guidelines) or organ systems (1995 guidelines) required for a specific level of exam, than you can’t code that level of exam.

Insufficient documentation of history was another major reason for denying or downcoding claims when documentation was submitted. Of course, the level of history depends on the history of present illness; review of systems; and past, family and social history. You will need to review your documentation in each of these areas to ensure that your documentation of history is satisfactory. Take a good look at how you gather and update patient histories. Do your new patients fill out a thorough questionnaire? How detailed are your nurse's pre-exam questions and notes?

Also remember that while nurses or other clinical staff can record the review of systems and past, family and social history, the physician's documentation must supplement or make it clear that the physician reviewed and confirmed the information that the other staff member gathered.

Some other simple things you can look for to make sure you are coding correctly are:

• The time spent does not control the level of service to be billed unless more than 50% of the face-to-face (for out-patient services) is spent providing counseling or coordination of care.  If the documentation does not indicated counseling or coordination of care then time cannot be factored into the selection.

• A physician can only bill for one hospital visit per day for the same patient regardless of whether or not the problems seen during the encounters are related.  The physician should select the code that reflects all services provided during the date of service.

• If a new patient comes in for a visit. And the physician does a history and discusses the reason for the visit with the patient and refers the patient out to a specialist without performing a physical exam, you can only bill a low level new patient visit as long as the physician documents properly.  Recommendation could be that a Level II E& M code (99202) be used.

• If the patient comes to a specialist office with a referral from another physician, then a new patient E&M code should be used.  For an office visit to be a consultation (as long as the patient is not a Medicare patient) it needs the 3 R’s:  (1) Request from a physician, (2) An opinion to be rendered, and (3) a report sent back to the referring physician.

• If it wasn’t documented it wasn’t done.  

• The term New Patient is used for patients who have not received face to face professional services from the physician within the last 3 years.  In a group practice, a patient is considered “new” to a physician if the patient has not been seen by another physician of the group WHO IS IN THE SAME SPECIALTY in the last three years.

• An E& M office visit cannot be billed on the same day as a hospital or nursing facility admission

A minimum of an annual review of your documentation and coding is recommended to address any areas for improvement and to ensure the documentation supports the levels of service billed.