How do healthcare providers accurately use Evaluation and Management (E&M) codes for proper reimbursement?

Accurate E&M Coding for Proper Reimbursement

Healthcare providers must understand that E&M coding requires documentation that supports clinical decision-making rather than simply documenting to meet billing requirements, as nearly half of all E&M visits for Medicare patients are coded incorrectly according to the Office of Inspector General. 1

Understanding E&M Documentation Guidelines

The Evaluation and Management (E&M) guidelines have fundamentally changed how physicians document patient encounters, shifting focus from what was clinically done to what is documented:

• E&M guidelines were created to provide an externally verifiable measure of cognitive services, but have created a complex system with format requirements that are difficult to understand and use 1
• The guidelines use confusing terminology like "expanded problem focused" that makes determining service levels cognitively challenging 1
• Documentation has become a two-step process: caring for the patient, then "backfilling" notes to fit documentation requirements, often including clinically irrelevant elements 1

Common E&M Coding Pitfalls

• Nearly 40% of E&M claims are miscoded, with 26% upcoded and 14.5% downcoded, representing significant compliance risks 1
• Documentation often includes boilerplate negative findings to satisfy guidelines rather than clinically relevant information 1
• The primary focus has shifted from clinical care to compliance, coding, and security concerns 1

Best Practices for Accurate E&M Coding

Documentation Principles

• Focus documentation on supporting patient care and improving clinical outcomes through enhanced communication 1
• Include the patient's story in sufficient detail to accurately retell it 1
• When appropriate, use macros and templates to improve completeness and efficiency, particularly for standardized elements like review of systems 1
• Document the type of encounter (new problem, chronic problem review, test interpretation, etc.) to demonstrate expertise and decision-making complexity 1

Time-Based vs. Medical Decision Making (MDM) Coding

• As of 2021, time and medical decision-making are the sole determinants of E&M level for office and outpatient visits 2
• When using time as the determining factor:
  • Document total time spent (including non-face-to-face work on the same day)
  • Specify that more than half the time was spent on counseling/coordination of care when applicable 1

Specific Code Selection Guidance

• For new patient evaluations that are detailed and moderately complex or take at least 45 minutes, use 99204 1
• For established patient visits that are detailed and moderately complex or take at least 25 minutes, use 99214 1
• For developmental screening, use 96110 in addition to E&M services provided on the same date 1
• For prolonged services, use appropriate add-on codes:
  • 99354 for first 30-74 minutes of outpatient face-to-face prolonged services
  • 99355 for each additional 30 minutes 1

Electronic Health Records and E&M Coding

• EHRs were initially designed to help physicians "right code" and avoid audit findings of unintentional billing fraud 1
• However, EHRs have not significantly reduced coding errors compared to paper records 1
• When using EHR tools:
  • When data are pulled from another location in the chart, indicate the source and supplement with appropriate narrative content 1
  • Use the "review/edit and/or attest, and then copy/forward" process carefully to improve accuracy without compromising quality 1

Avoiding Compliance Issues

• Document all telephone encounters for which a patient is charged in the medical record 1
• Include date, time, patient information, reason for call, total encounter time, relevant history, assessment, plan, and disposition 1
• Understand that improper E&M coding can lead to accusations of billing fraud, with potential for fines, exclusion from Medicare/Medicaid programs, and even criminal penalties 1

Improving Coding Accuracy

• Provider education and feedback systems have been shown to significantly improve coding accuracy, with one study showing an increase from 40% to 70% accuracy after implementation 3
• Regular billing audits can identify patterns of upcoding or downcoding that need correction 3
• Develop "chart etiquette" principles and policies based on well-defined standards within your organization 1