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 …
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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