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Maximize Reimbursements By Complete E/M Documentation and Coding

February 28, 2013

E/M Documentation and Coding

It’s been a busy week at the M-Scribe Atlanta office, where we spend most of our days making outpatient billing practices perfect. This past week, we tackled that hardy perennial topic: how to bill Evaluation and Management (E/M) services. With the institution of 1995 and 1997 guidelines, you would think that the methodology behind determining E/M levels would be well established by now. Medical billing professionals know that this isn’t always the case.  

Part of the problem, of course, is that the two guidelines don’t always produce the same results. An auditor reviewing a documented patient encounter using the 1995 guidelines will come up with one code, 99214, for instance, while another auditor using the 1997 guidelines will come up with another code, such as 99213. This is why auditors use both methodologies to review E/M codes. Findings in a provider’s favor come in an “either/or” form. They are either correct according to 1995, or they are correct according to 1997. Sometimes they are both, and sometimes they are neither. They should never be neither.

How the contents of a SOAP note translates into E/M codes is just one of the many conundrums that medical coders come across when trying to explain documentation requirements to healthcare providers. Of particular interest around our office this past week, was translating the component of time into evaluation and management services as defined by Current Procedural Terminology (CPT).

For established outpatient visits that require the presence of a physician, CPT requires that history, examination, and medical decision-making be documented. For example, the code 99213 requires a combination of two out of three of the following components for the patient encounter: 

  • An expanded problem focused history;
  • An expanded problem focused examination;
  • Medical decision making of low complexity.

The counseling and coordination of care need to be consistent with the patient’s condition and the patient’s and/or their family’s needs. CPT goes on to state that the patient’s condition is typically of low to moderate severity, and that fifteen minutes is the usual amount of time spent face-to-face between the physician and the patient and/or family.

“One of our doctors always spends a half hour with some of her patients,” one of our clients told us. “Can you see if these are being billed correctly?” our client asked.

Of course we can. Reviewing documentation is one of the things M-Scribe does best. 

M-Scribe documentation and coding professionals look at the seven components that are used in defining the levels of E/M services. These components are:

  • History
  • Examination
  • Medical Decision-Making
  • Counseling
  • Coordination of Care
  • Nature of Problem Presented
  • Time

Out of seven, the first three, i.e., history, examination and medical decision-making are the key components in selecting the level of E/M services. In the case of visits consisting predominantly of counseling or coordination of care, time is the key or controlling factor to qualify for a particular level of E/M service. For more information about E/M documentation please visit Documentation.


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