E&M Coding: What Not to Do

Correct coding and billing for evaluation and management (E&M) stymies many practices. Medicare payers have identified these E&M codes, especially, as problematic: 

  • 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

Common errors associated with these codes are as follows.

  • 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 decisionmaking 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.

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 email TMA Practice Consulting .

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Revised April 30, 2014.

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Last Updated On

April 30, 2014