The evaluation and management (E/M) patient visit is the foundation of most physician practices, however many providers are uncertain how to choose the correct Current Procedural Terminology (CPT) code for an E/M visit, thereby losing revenue.
The underlying problem is two-fold: first is not understanding how the coding system for E/M visits works (CPT codes 99201 through 99205 for new patients, and 99211 through 99215 for returning patients); second is inadequate documentation to support their choice of code.
When providers are uncertain what code to use, many will instinctually avoid risk by downcoding. A 2012 audit conducted by the American Academy of Professional Coders (AAPC) found that more than a third of the records were either undercoded or under documented. This represents an average of $64,000 in foregone or at-risk revenue per provider.
Many providers think from a clinical perspective and not about documenting the record to support the codes.
Complexity level is key to coding
The correct code for an E/M visit is generally tied to the complexity of the visit, which is determined by the number of problems and the extent to which they are addressed.
Three components determine the appropriate billing level for an E/M visit:
3. Medical Decision-Making
Each of these components has various levels of complexity and sub-components. For example, a history can be “problem-focused,” “expanded problem-focused,” “detailed,” or “comprehensive.”
The proper level of complexity is determined by the presence or absence of documentation for four sub-elements:
1. Chief Complaint
2. History of Present Illness
3. Review of Systems
4. Past/Family/Social History
The complexity levels for an examination are the same as those for history, while the complexity levels for medical decision-making are “straightforward,” “low complexity,” “moderate complexity,” and “high complexity.”
Among the three components, medical decision-making represents the biggest challenge in terms of documentation and interpretation. While history and exam can be documented with checkboxes and objective quantification, medical decision-making is not as easily quantified
Documentation is crucial
The key to supporting medical decision-making choices is to thoroughly document what was done for the patient and why. This documentation can be approached in a “problem-based” way.
Documenting the medical issues you are dealing with during the visit will also facilitate an external coder or auditor being able to pick out the number of diagnoses you’re dealing with, which is a major part of medical decision-making.
Some common examples of not fully documenting decision-making include providers neglecting to note explicitly that they’ve personally reviewed imaging, and obtained historical information about a patient from someone other than the patient, such as a family member or caregiver.
EHRs can lead to upcoding
The widespread use of electronic health record (EHR) systems has in some ways contributed to coding problems by prompting providers to document at a level beyond what the encounter really requires – known as upcoding.
In some cases, the E/M calculator tool may suggest a code that is too high based on the information automatically populated by the EHR.
As a result, providers need to not only document the service properly, but must also consider whether the documented service was medically necessary.