E&M Coding: What Not to Do

Correct coding and billing for evaluation and management (E&M) continues to stymie many practices. TrailBlazer, the Medicare contractor for Texas, has found these E&M codes to be most problematic among the claims it processes: 

  • New patient office or other outpatient visits - CPT codes 99201-99205
  • Established patient office or other outpatient visits - CPT codes 99211-99215
  • Initial hospital care for new or established patient - CPT codes 99221-99223
  • Subsequent hospital care - CPT codes 99231-99233
  • Emergency department services - CPT codes 99281-99285
  • Nursing facility services - CPT codes 99304-99306 and 99307-99310
  • Consultations - CPT codes 99241-99245 and 99281-99285

TrailBlazer identified these common errors associated with the above codes:

  • Documentation is incomplete/insufficient:

    • Documentation does not support the level of service billed (i.e., upcoding or downcoding of services).
    • Required components (as required by the CPT book) are not documented in the medical record.
    • The history component is incomplete or absent.
    • The medical decision-making documented is inappropriate or incomplete. Services were rendered by one physician and billed by another.

  • Documentation does not support a face-to-face encounter between physician and patient.
  • The medical record contains conflicting information (e.g., the diagnosis on the claim is inconsistent with the diagnosis in the medical record; documentation in the patient's history conflicts with the examination; the date of service in the documentation is different from the date of service billed).
  • The service is not performed on the date of service billed, not dictated on the date of assessment, or not documented on the date of the visit.
  • Medical documentation does not support medical necessity for the frequency of the visit.

Consultations have some unique properties when compared with other E&M services. TrailBlazer found several common recurring documentation deficiencies based on its review of physicians' documentation for inpatient consultation services and office consultations. These include:

  • Services reported as consultations are presurgical history and physical (H&P).
  • There is no written or inferred request of [for?] an opinion.
  • There is no written report to the requesting physician.
  • Follow-up care is billed as a consult after transfer of care to the consulting physician. 

Coding errors result in payment delays, underpayment (e.g., if you undercode), or even an audit (e.g., if you habitually overcode). TMA Practice Consulting can help TMA members and their staff get a handle on E&M coding. TMA consultants can perform a complete coding and documentation review for your practice or an abbreviated coding and documentation check-up , or provide on-site training on how to audit your own records, and avoid coding and documentation errors.

For more information, contact a TMA consultant at (800) 523-8776 or e-mail TMA Practice Consulting .

For self-help, download these handy guides ( PDF ) from the Centers for Medicare and Medicaid Services and TrailBlazer:

TMA Practice E-tips main page


Comment on this (Must be logged in to comment)

Add Comment

Text Only 2000 character limit

Looking for more?