ACK Coding Tips
Tips for E/M Usage
Getting paid for providing medical services
today is exponentially more complicated than it was just a few decades ago.
That's why it's important to review the basics of evaluation and management
(E/M) coding and immediately start applying the guidelines with confidence.
Many
coding articles have been written with the assumption that physicians have a
basic understanding of E/M coding guidelines or that—even without this basic
understanding—learning a few tips will improve coding accuracy. For many of
them, this assumption leads to more frustration and confusion. One reality that
often is overlooked in coding education for physicians is that E/M
documentation requires them to do something that they were never trained to do.
In medical school, they are taught to document two things: a history and
physical exam, and a subjective, objective, assessment, and plan, or SOAP,
note. For the most part, the documentation is intended for their future
reference, for communication with other providers, and to satisfy "the
standard of care" imposed on us by the legal profession.
In contrast to how documentation is viewed from the
medical perspective, documentation from an E/M perspective, as its history
would suggest, attempts to translate into a payment level the amount and
complexity of work they do. This coding perspective and its system of
documentation are not taught in medical school and too often are not taught in
residency. Similarities exist between the two ways of looking at documentation,
but the origin and purpose are different.
Many
physicians who code inaccurately purposely under-code erroneously, believing
that doing so is a viable means of navigating the complicated coding system. In
addition to lost revenue, this approach makes them more likely to stand out
against others in their specialty and possibly be targeted for audit.
An overall trend for physicians has been to
code higher-level visits. This trend is striking for established patient codes
paid by the Centers for Medicare and Medicaid Services (CMS) in family medicine
from 2006 to 2010
If you deviate significantly from the national
benchmarks, you likely will be audited. At least in theory, having a
distribution of Current Procedural Terminology (CPT) E/M codes consistent with
the national benchmark for your specialty should minimize the likelihood of a
CMS audit. Even if your coding patterns match national benchmarks, however,
it's still important to ensure that the coding accurately reflects the
documentation. Nonetheless, the reality is that, over time, many doctors have
been coding higher-level visits.
Perhaps
electronic health record (EHR) systems and template use may help some doctors
document higher-level visits, but decreased revenues may be putting pressure on
all physicians to capture lost charges that previously would have been
under-coded. Whatever is causing the trend, it is important not only to know
how your practices compare with national benchmarks but to have a firm grasp on
the fundamentals of E/M coding. To do so will minimize lost revenue and the
potential to be audited and potentially charged with fraud.
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