Physicians and Medicare alike have struggled for many years with correct coding, documentation, and payment of evaluation and management (E&M) services. That’s because, by their nature, E&M services are a diverse set of cognitive procedures, making them difficult to quantify.
The Carenodes medical executives offer the following highly simplified but useful “bottom-line” E&M coding advice.
Regardless of how much history, physical examination, and/or medical decision-making related to an E&M encounter are recorded.
-
Do not consider reporting the highest two codes of any code family:
-
When fewer than three distinct medical conditions/complaints were evaluated and managed during the encounter,
OR -
No problem evaluated and managed, without appropriate intervention, conferred at least a 50/50 likelihood of worsening, disability, or death between the time of the current encounter and the next physician encounter.
-
Do not consider reporting the highest codes of any code family:
-
When fewer than four distinct medical conditions/complaints were evaluated and managed during the encounter,
OR -
No problem evaluated and managed, without appropriate intervention, conferred at least a 50/50 likelihood of worsening, disability, or death between the time of that encounter and the next physician encounter.
This approach simplifies coding E&M services by eliminating from consideration the highest-level codes for reporting services that – by their clinical nature – usually do not require a detailed or comprehensive history and physical, high- (and sometimes moderate-) complexity medical decision making, or lengthy counseling and coordination. It addresses the most common source of known Medicare E&M coding errors: failure of medical records to demonstrate the work of and/or medical necessity of higher level E&M services reported for payment.
