Protect the integrity of your practice’s medical records with this sage advice.
Evaluation and management (E/M) services are likely the most regulated and most often audited services in medical practices. These services can account for more than half of a provider’s income, so it is crucial that they are appropriately documented and coded. A casual approach to E/M coding can result in both improper reimbursement and embarrassing audits. Professional coders in medical practices have a responsibility to ensure that E/M services are properly coded.
To ensure correct E/M billing, the documentation must meet certain minimum tests. Each of these “10 commandments” reflects an area integral to uncontestable documentation and coding. Coders can use this list to assess the records found in their workplace, and then address areas of concern with providers.
1. The documentation must be legible.
Legibility is the bedrock of a medical record. Obviously, if a record cannot be read or interpreted, it is of little value. This does not mean that the record must be meticulously written. There are many providers whose handwriting falls far short of perfection. However, with a little help, the coder or auditor should be able to handily decipher the provider’s documentation. Dictated or computer-generated records can be a great benefit in this area, although they are not without their pitfalls, as outlined below.
2. Every record contains basic data.
Each record must contain the patient’s name and birth date, as well as the encounter date and time, and the location of the service. The nurses or medical assistants of a practice should be trained to record these as they assess the patient. Upon completion, every record must be signed by the provider, whose printed name should also be a part of the record. Necessary components, according to the American Medical Association (AMA), include a medically appropriate history and/or exam (not necessary for code selection of office or other outpatient services beginning Jan. 1, 2021) and medical decision making (MDM) or total time on the date of the encounter.
3. The record should be organized.
Haphazard documentation makes the record difficult to follow and can lead to coding errors. Medical records should “chronologically report the care a patient received and record pertinent facts, findings, and observations about the patient’s health history,” per the Centers for Medicare & Medicaid Services’ (CMS’) Evaluation and Management Services Guide.
4. Documentation matches the billed services.
Unfortunately, it is not uncommon for providers to list several of a patient’s past and active diagnoses on a superbill or in the record, when the record documents care for only one or two of them. Every billed service and its corresponding diagnosis code must be clearly documented in the medical record. Having a laundry list of past problems not addressed during the encounter means the coder will need to determine which ICD-10 codes to report to represent conditions actively treated for that encounter.
5. Medical decision making matches service level.
When MDM is the overriding determinant of the level of service, documentation should include the level of MDM, number and complexity of problems addressed, amount and/or complexity of data to be reviewed and analyzed, and risk of complications and/or morbidity or mortality of patient management.
6. Addendums or alterations are properly documented.
The integrity of the medical record is paramount and can only be protected by strict adherence to rules regarding timely completion and proper notation of late changes. Ideally, an encounter should be fully and completely documented “during the encounter or as soon as practicable after the encounter,” according to CMS’ Evaluation and Management Services Guide. Additions to a completed record should be clearly labeled as such, and include the date, time, and reason for the addendum. When making a late addendum, it is preferable to place it on a separate page from the original document to avoid the impression that the author was attempting to alter the original record.
7. Do not clone medical records.
Cloning medical records refers to the abusive use of boilerplate data or carrying forward large portions of a patient’s prior record to the current encounter. When documentation is “cloned,” it implies that information is inserted into the record that has not genuinely been elicited from the current encounter. Cloning usually occurs in the context of using an electronic medical record. Detecting and eliminating the practice of medical record cloning is part of the Office of Inspector General’s Work Plan. Be sure your providers are aware of this potential pitfall.
8. Do not abuse modifier 25.
Some providers bill encounter codes improperly appended with modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service. Modifier 25 is proper only when a separately identifiable E/M service is performed at the same encounter as another service. The E/M service can relate to the procedural service, but it must represent service above and beyond what is normally included in the procedure. For example, an established patient presenting for routine cryotherapy of warts would probably not qualify for an E/M service. However, a new patient presenting for the same problem would need an E/M service to take the initial history and perform an initial physical examination.
9. The necessity of ancillary testing is clear.
When testing or procedures are part of the encounter, the reason and necessity for these items must be clearly documented or intuitively obvious to medical personnel. A Pap smear is understandably part of a routine gynecological examination and does not need special documentation. However, in many cases, it may take a few words of explanation to clarify why certain tests were included in the encounter. While “rule out” diagnoses are not valid to submit for professional billing purposes, they can be used in the text of the record to explain the need for testing.
10. Set your watch for time-based encounters.
When time-based billing is used to report an E/M service, the documentation should justify the time spent, precisely. Documentation should include time spent performing non-face-to-face services the day of the visit. For all but office and other outpatient E/M services, documentation must indicate that counseling and/or coordination of care dominated the service.
These 10 commandments cover the most important facets required for precise E/M coding. Adhering to these principles will help ensure that your practice’s documentation and coding are sound and able to withstand payer scrutiny.
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Originally Published On: AAPC Forum
Photo courtesy of: Getty Images
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