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ICD-10 and Evaluation and Management (E&M) Coding

March 22, 2013

M-Scribe E/M Coding and BillingEvaluation and management (E/M) coding is the bread and butter of a primary care office’s practice. Internal medicine doctors, family practitioners, pediatricians, and general practitioners all rely on accurate E/M coding and billing. Being able to define the level of professional services delivered, based on documented physician work, requires professional billing staff and a thorough familiarity with the E/M requirements in CPT as well as the documentation requirements for diagnosis coding. 

Specificity of diagnosis codes is about to undergo a radical realignment, with greater specificity being the new paradigm. ICD-10 billing is revolutionalizing how healthcare claims get adjudicated and paid. The greater specificity of the codes found in ICD-10-CM will provide third party payers a more accurate picture of the patient’s health and of the reasons the patient is receiving care. The justification of medical necessity will be more apparent due to the new electronic edits that will read the new codes.

This may be a worrisome development for some primary care providers. Many of them are used to documenting to the level of ICD-9 coding. The whole reason for the new ICD methodology is that ICD-9 has too many vague codes that can have multiple interpretations.  What this means in practice is that payers don’t always know why they are paying for procedures. The codes on the healthcare claim don’t provide specific enough information.

A complete medical record will contain all the information needed to render a patient’s diagnosis into a 7-character ICD-10 code. However, not all medical record entries are as complete as they could be. Because ICD-9-CM does not require the same degree of information to support a code, some physicians have gotten used to documenting to support “not otherwise specified” codes. There has never been any penalty for this, nor an incentive to document more completely from a billing standpoint, because ICD-9-CM cannot help but report incomplete information.

ICD-10-CM is going to change that. The specificity of ICD-10 codes means that a third-party payer or auditor will know exactly what the patient’s condition is. The medical record will have to support that degree of specificity. An ICD-10 code contains a lot of information, enough to indicate if a procedure is justified much more so than many ICD-9 codes.

What does this have to do with E/M billing for primary care providers?

A complete ICD-10 code will give a clear indication if a patient’s inherent risk, or the severity of their condition.  There are already payers that limit the level of E/M service provided for some diagnosis codes. A common example is an edit to automatically re-code an encounter for alopecia 99212. With ICD-10 codes, more payers will be able to tailor their edits to the more specific information.

Accurate coding is the hallmark of a successful medical billing practice. Doing things the right way the first time leads to quicker reimbursement, fewer appeals, and fewer denials. At M-Scribe, our medical documentationists are working closely with our clients to prepare for the ICD-10 transition.

M-Scribe Helps Providers with Their E&M Coding Levels

Less-than-thorough documentation is going to lead to less-than-accurate codes being submitted under ICD-10. This in turn can lead to those claims receiving increased scrutiny from payers. The more accurate the coding, the less chance there is for exposure to charges of fraud or abuse. Practices that employ billing and documentation professionals have less need to worry in the case of a RAC audit. They already know that their coding matches the medical record, which accurately describes the patient encounter. Good coding comes from good medicine.


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