How To Use the Evaluation & Management (E&M) Codes Properly:

Part III: Mastering the E/M Guidelines

The Chiro.Org Blog

SOURCE:   Chiropractic Economics

By Kathy Mills Chang, MCS-P

Part III:   Mastering
the Evaluation & Management
(E&M) Guidelines

Jump to:   Part 1 or Part 2

The medical decision making component ties it all together.

Welcome to part three this focus series on the evaluation and management (E/M) guidelines. This will wrap up what you need to know to stay compliant with E/M coding for the Centers for Medicare and Medicaid Services (CMS).

In the last installment, the elements of your patient’s examination were reviewed and you learned how it is the second of the three key elements of the patient’s E/M service. Now, the third part of this E/M documentation series will unravel the final component of the E/M code: medical decision making (MDM). For chiropractors, this is usually the diagnosis and treatment plan.

Three key components of the E/M guidelines:

  1. Patient history
  2. Examination
  3. Medical Decision Making (MDM)

Remember that your patient’s medical record should establish a chronological record of exams, tests and results, and treatments and treatment plans (including the diagnosis and prognosis of the illness or disease). The medical record should corroborate the reimbursement request and is requisitioned by most payers for adjudication of claims when reimbursement is in question.

Your medical recordkeeping is a vital piece in the puzzle of reimbursement. Therefore, a clear understanding of all requirements, including those of MDM is critical.

MDM is fraught with controversy and confusion, and it is the most difficult of the three components of E/M coding.

Three subcomponents of MDM that must be considered:

  1. The number of diagnoses and/or management options that must be documented in the patient record.
  2. The amount of data that is to be reviewed.
  3. The risk of complications, morbidity, and/or mortality.

MDM should reflect your cognitive work, clinical skill, and judgment in rating the complexity of the decision- making process as well as the complexity of the diagnosis and therapeutic options. More than the other parts of E/M (the history and exam), it will likely be the MDM component that determines the level of E/M service you are able to bill, especially for a new patient.

Because MDM can be conceptually challenging, there are some doctors who simply guess at the medical decision-making levels (it certainly doesn’t help that the MDM guidelines leave much unstated and not clearly understood). According to the Office of Inspector General (OIG) and CMS, chiropractors seem to consistently lag behind other professions when it comes to proper coding and documentation.

Moreover, there are numerous doctors who consistently under-code their levels of E/M service, mistakenly believing that this allows them to fly under the radar of auditors. It is important to know that under-coding is as bad as over-coding claims, and is in direct violation of the False Claims Act (when done purposely). In addition, there are fines and penalties that can be imposed on any person who knowingly submits a false claim for payment.

As a general rule, each increase of one E/M level (e.g., increasing from 99201 to 99202) increases the usual and customary fee for the code by about 50 percent. Some doctors think of their medical decision making as “routine” and select a straightforward MDM.

If you are meeting the documentation requirements for billing higher level E/M codes, and are doing the work, you have every right to be paid for it. But your documentation must reflect the correct elements of MDM to justify the code.

On the flip side, doctors tend to believe they can justify a higher level MDM code because the patient they are seeing is in severe pain or experiencing many symptoms. This isn’t necessarily how it works.

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