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

Accurate E&M Coding for Proper Reimbursement

Healthcare providers should use either time-based coding or medical decision-making (MDM) complexity as the sole determinants for selecting E&M codes, with documentation focused on accurately reflecting the clinical encounter rather than simply meeting billing requirements. 1, 2

Current E&M Coding Framework (2021 Guidelines)

The 2021 revisions simplified E&M coding by eliminating history and physical examination as determining factors, leaving only two pathways for code selection 2:

• Time-based coding: Document total time spent on the encounter, including non-face-to-face work performed on the same day of the visit 1
• MDM-based coding: Document the complexity of clinical decision-making, including the type of encounter (new problem versus chronic problem review) to demonstrate expertise and decision-making complexity 1

Specific Code Selection Guidelines

For new patient visits 1:

• 99204: Use for detailed evaluations that are moderately complex OR take at least 45 minutes

For established patient visits 1:

• 99214: Use for visits that are detailed and moderately complex OR take at least 25 minutes

Critical Documentation Principles

Document the patient's story in sufficient detail to accurately retell it, focusing on supporting patient care and improving clinical outcomes rather than simply meeting billing requirements. 1

Key documentation elements include 1:

• Type of encounter (new problem, chronic problem review, preventive care)
• Total time spent when using time as the determining factor
• Clinical decision-making complexity and rationale
• All telephone encounters for which patients are charged (date, time, patient information, reason, total time, relevant history, assessment, plan, disposition)

Common Coding Errors and Compliance Risks

Nearly 40% of E&M claims are miscoded, with 26% upcoded and 14.5% downcoded, representing significant compliance risks 1. The Office of Inspector General reports that nearly half of all E&M visits for Medicare patients are coded incorrectly 1.

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

Common pitfalls to avoid 1:

• Including boilerplate negative findings to satisfy guidelines rather than clinically relevant information
• Using documentation that doesn't accurately reflect what occurred during the patient-physician encounter
• Failing to indicate the source of pulled data from EHR systems

Electronic Health Record Considerations

When using EHR tools for E&M coding 1, 3:

• One-click templates and macros for normal findings are acceptable time-saving functions, but the final signed documentation must accurately reflect what occurred during the encounter
• Indicate the source of pulled data and supplement with appropriate narrative content
• Avoid "cloned" documentation where each entry is worded exactly like previous entries, as this is considered misrepresentation by CMS 3
• Shortcuts to bring forward history from previous encounters are acceptable only if verified and updated by the physician 3

Improving Coding Accuracy

Provider education and feedback systems can significantly improve coding accuracy. 1

Implement these strategies 1, 4:

• Develop "chart etiquette" principles and policies based on well-defined standards within your organization
• Use multidisciplinary team-based coding interventions to ensure documentation accurately reflects complexity of care delivered
• Focus on clinical documentation that is brief and thoughtful, efficiently conveying findings, thought processes, decisions, and actions taken 3

Accurate coding that reflects true complexity of care can result in substantial revenue improvements—one academic center demonstrated an increase of $233,989 per 10,000 encounters by properly documenting care complexity 4.