Optimal Physician Services, LLC

E/M coding tips

Tips to Prevent Coding Errors

History

Do not limit the chief complaint to follow up without identifying the problem being followed.

Describe the history of the present illness fully and in such a way that the nature of the presenting problem is clear. Higher level services require four or more elements or the status of three or more chronic conditions.

Record Past/Family/Social History (PFSH) appropriately considering the clinical circumstance of the encounter. Extensive PFSH is unnecessary for lower-level services. This is often missing from medical documentation.

Record the Review of Systems (ROS) appropriate for the clinical circumstance of the encounter. Expansive ROS is unnecessary for lower-level services.

Physical Examination

The difference is not the number of systems examined. Two to seven systems are required for both. The difference is the detail in which the examined systems are described.

Always examine the system(s) related to the presenting problem.

Abnormal findings should be noted and expanded upon. Normal is sufficient.

Code the physical examination considering the clinical circumstances of the encounter. Do not code based on excessive and unnecessary information recorded solely to meet the requirements of a high-level service when the nature of the visit dictates a lower-level service to have been medically appropriate.

Medical Decision-Making (MOM)

Record relevant impressions, tentative diagnoses, confirmed diagnoses and all therapeutic options chosen related to every problem for which Evaluation and Management (E/M) is clearly demonstrated in the record of the other key components.

Document all diagnostic tests ordered reviewed and independently visualized as part of the work of the encounter. Be sure to document what was looked at and document the findings.

Summarize old records or other outside information reviewed and incorporated into decision-making.

Beware of templates that overestimate decision-making. Understand the logic of templates and/or computer programs used for E/M service coding.

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To review more information on the topic click on the link below to the Highmark Medicare Services website: 

https://www.highmarkmedicareservices.com/calendar/partb/webinar/index.html