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 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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