E&M Coding Advice

Physicians and Medicare alike have struggled for many years with correct coding, documentation, and payment of evaluation and management (E&M) services. That's because, by their nature, E&M services are a diverse set of cognitive procedures, making them difficult to quantify.

The medical directors at TrailBlazer Health Enterprises, the Medicare contractor for Texas, offer the following highly simplified but very useful "bottom-line" E&M coding advice. (Read a  more in-depth look at E&M coding  from the medical directors, too.)

Regardless of how much history, physical examination, and/or medical decision-making related to an E&M encounter are recorded …

  • Do not consider reporting the highest two codes of any code family:
    • When fewer than three distinct medical conditions/complaints  were evaluated and managed during the encounter,
      OR
    • No problem evaluated and managed, without appropriate intervention, conferred at least a 50/50 likelihood of worsening, disability, or death between the time of the current encounter and the next physician encounter. 
  • Do not consider reporting the highest codes of any code family:
    • When fewer than four distinct medical conditions/complaints  were evaluated and managed during the encounter,
      OR
    • No problem evaluated and managed, without appropriate intervention, conferred at least a 50/50 likelihood of worsening, disability, or death between the time of that encounter and the next physician encounter. 

This approach simplifies coding E&M services by eliminating from consideration the highest-level codes for reporting services that - by their clinical nature - usually do not require a detailed or comprehensive history and physical, high- (and sometimes moderate-) complexity medical decision making, or lengthy counseling and coordination. It addresses the most common source of known Medicare E&M coding errors: failure of medical records to demonstrate the work of and/or medical necessity of higher level E&M services reported for payment.

 

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