Despite of having proper guidelines, coding for Evaluation and Management (E/M) services is still a challenge for healthcare service providers. CMS reported that more than 15% of E/M services were improperly paid due to over or under coding of these services. Due to higher rates of errors, Reimbursement for providers has declined over the years. E/M coding errors results in claim denials which financially affects both the organization and practitioner.
There are number of strategies that will help you prevent your E/M claim denials:
- The reason for the visit should be properly stated.
- The history of the present illness should be described in such a manner that the nature of the problem is clear.
- Thoroughly study the documentation guidelines that specify elements to be recorded about the present illness.
- Unnecessary information should not be recorded to meet requirements of a high-level service when the nature of the visit is lower to have been medically appropriate.
- Record the Review of Systems (ROS) appropriate for the clinical circumstance of the encounter.
- Document an ROS for the system/systems related to the presenting problem. It is required for all for all codes except the least codes in all code families.
- Record both positives and negatives related to the presenting problem. Use notations such as “normal” or “negative” only for systems not related to the presenting problem.
- Record all the important impressions, tentative diagnoses, confirmed diagnoses and all therapeutic options related to every problem for which Evaluation and Management (E/M) is clearly demonstrated in the record of the other key components.
- Document all ordered diagnostic tests, reviewed and independently visualized as part of the work of the encounter.
Tips for Preventing Coding Errors:
- Understand Current Procedural Terminology (CPT) code requirements.
- All of the following codes require comprehensive history and comprehensive examination: – 99204 and 99205 (New patient office services). – 99222 and 99223 (Initial hospital services). – 99244 and 99245 (Office consultations). – 99254 and 99255 (Initial in-patient consultations).
- Proper attention should be given to the unique record kept in Emergency Departments (EDs).
- Physician coding should be based on the physician’s own Evaluation and Management (E/M) work.
- While coding for E/M services attention to medical necessity should be given. When coding, consider contributory factors and/or other patient status descriptions.
The message from Medicare Administrative Contractors (MACs) is that E/M services are a top contributor to the Comprehensive Error Rate Testing (CERT) error rates, and that there is an obvious need for education among providers.