The difficulties with E&M coding, appropriate billing, and controversies over some of the E&M rules are discussed. Trends in coding over time and how that influences healthcare delivery are also explored.
2. For E&M Coding, Understand Current
Challenges
Controversies
Trends
3. Guidelines do not define criteria for
Number of diagnosis or treatment options
Amount and complexity of data reviewed
Each Medicare carrier has discretion in this
area
Fortunately, most now use the same criteria
4. When comparing 136 certified professional
coders..Type of
encounter
Undercoded Coded
Correctly
Overcoded
Established
Patient
24% 59% 17%
New Patient 8% 59% 33%
This study compared E&M coding for 6 sample patient encounters by
136 certified coders with an average of 10 years of coding
experience. The coding level with the highest level of agreement was
considered the correct level. Overall agreement on coding level was
59%
5. When compared to expert coders, FP
physicians..Type of
encounter
Undercoded Coded
Correctly
Overcoded
Established
Patient
33% 51% 16%
New Patient 1% 17% 82%
This study compared E&M coding for 6 sample patient encounters by
198 FP physicians and professional coders. Coding by professional
coders was considered to be accurate for the purposes of this study.
J Am Board Fam Pract 2001;14:184-92
6. Undercoding is a major problem
An audit of 351 Family Practice notes
showed…
Undercoded
33%
Based on audit of documentation
Shows rate of actual undercoding.
South Med J. 2010 Apr;103(4):316-22
7. Worse if just considering MDM
An audit of 351 Family Practice notes
showed…
Undercoded
50%
Based on audit of MDM documentatio
Approximates what could have been
coded if properly documented in
History + Exam sections.South Med J. 2010 Apr;103(4):316-22
8. Worse if considering presenting
problem(s)
An audit of 351 Family Practice notes
showed…
Undercoded
80%
Based on audit of presenting problem
Approximates what could have been
coded if properly documented for
History + Exam + MDM
South Med J. 2010 Apr;103(4):316-22
9. Example – Hospital Admission
Initial
Inpatient
Evaluation
CPT Code
Medicare
Allowable
Charge
RVUs
Level 3 99223 $204 3.86
Level 2 99222 $138 2.61
Level 1 99221 $102 1.92
2014 Medicare Physician Fee Schedule, National Payment Amount, Accessed
Undercoding by just one level reduces the Medicare Allowable Charge by 26-33%
15. Set level with MDM
Document History/Exam to support level
Consider
E&M coding software
Documentation templates
17. Model used by 75% of practices in 2012/2013 Merritt Hawkins Survey
18. Complex Rules
Consider
E&M Coding Software
Documentation Templates
Mastery of the rules relevant to your practice is
essential for financial success