Evaluation and Management (E/M) services-an important revenue source for providers nationwide-have long been under scrutiny by payers and government agencies. Most denials and payer reviews that result in down coding or recoupment of funds are due to lack of documentation to support medical necessity. As such, it is imperative that providers understand how CMS and other payers define medical necessity.
Medical necessity encompasses the patient's need for care, as recorded in the chief complaint, physical observations, and the amount of necessary work performed by the provider through data review, diagnostics, orders, and treatment planning including anticipated progress or outcome. Generally, E/M services are assigned based on the extent of documentation, including the patient's history, exam, and the provider's medical decision making-although medical necessity ultimately defines the level assignment.
Record the History with Care
The history component is often the least documented portion of the encounter. The history includes the chief complaint or diagnosis, described in detail by history of present illness (HPI) elements and supported with a relevant review of systems (ROS) to establish important factors that affect the medical decision-making and treatment. The history also contains a brief explanation of symptoms, location, severity, duration, previous treatments or other modifying factors, quality of life, and the big picture in context to the disease being managed. Documentation of co-morbidities as identified by the ROS and any contributing personal, social or family history provides a connection to the work involved to develop the assessment and plan promoting a cohesive presentation of the quality of care that supports the overall medical necessity for the encounter.
Choose the Guidelines That Suit Your Situation
Providers currently have the opportunity to choose either 1995 or 1997 E/M documentation guidelines, based on the patient's presenting problem and extent of exam performed; through correct application of these guidelines the E/M level assignment may be significantly increased.
Each set of guidelines contains the same requirements for history and medical decision-making, although the examination requirements are different. CMS 1995 guidelines for exam include body areas /organ systems. The 1997 guidelines implemented the use of elements within each organ systems, using either general multi-system exam or a specialist single-organ system exam.
Depending on the provider and practice type, each set of guidelines offers unique benefits to improve compliance and revenue. A specialist may be very successful using a specialty single-organ exam with 1997 guidelines. In contrast, another provider of the same group may benefit from using the 1995 body area examination. CMS has published a complete guide for utilization of both 1995 and 1997 guidelines, which are available at http://www.cms.gov/medlearn.emdoc.asp. A comparison of the two systems may be found at http://www.cms.gov/medlearn/appendix1.pdf.
Tailor Language to Condition Severity
Providers must use adequate vocabulary to describe the severity of the patient's condition, and the care that is being provided at each encounter. When specific terms such as "routine," "stable," "controlled," or "no complaints" are included in the documentation, it is indicative to a situation requiring only straightforward-or at most a low-complexity-medical decision-making. The provider should include details describing the severity and treatment(s) that accurately represent the clinical value being provided to the patient. Some common phrases used during assessment and planning are: "improving," resolving with Rx mgt," "2 week follow up apt for diabetic teaching," "physician conference for chronic disease management," "close monitoring for toxicity," "poor prognosis" and "high risk medication monitoring."
Assessments that include failed treatments, new medications, any procedure scheduled, new orders for durable medical equipment, or home health care, represent an increased patient risk. Such assessments require a higher level of decision making by the provider, which equals a more complex level of medical necessity.
Consults Require Careful Documentation
Providers frequently fail to include all the information to document consultation services appropriately.
Consults require a request, a reason, and a response to the requesting physician. A providers' use of the preferred vocabulary when performing consults will distinguish clearly these services from a transfer of care.
As part of the chief complaint, providers should state that the patient is being seen at the request of "the physician's name" for an opinion of "specific condition," such as candidacy for surgery. The consultant should provide a statement of opinion or recommendation provided back to "the requesting physician name."
Time Can Be Crucial To E/M Level Selection
Time-based billing is a valuable way to optimize revenue in rare situations-although time should not routinely be included in documentation, nor should time based billing be standard practice.
When a provider spends 50 percent or more of the face-to-face encounter counseling the patient, the total time and the counseling time should be documented with a description of the discussion. This allows for a higher level of service to be billed based on time when the components as documented would not have qualified for that service level assignment.
For example, a patient presents with terminal cancer. The provider performs a problem-focused history and exam, then discusses possible palliative care treatment options verses hospice enrollment for 30 minutes. The total time of the visit is 45 minutes. A typical problem-focused office visit for an established patient would be reported as a 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 10 minutes face-to-face with the patient and/or family. Based on the time spent counseling, however, this visit may be reported using 99215 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A comprehensive history; A comprehensive examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family.
Careful Coding Pays Dividends
E/M services historically are proven to have a high error rate of reporting. Healthcare reform initiatives continue to reduce provider payments, while targeting known areas to recover improper payments. The rising costs of healthcare and limited resources have created an overwhelming need for certified coders with specialty training. A certified coder specializes in reporting proper coding, applying the existing guidelines to achieve that most benefit to the provider, while improving compliance and revenue through individual documentation reviews. To remain profitable, providers should take individual initiative to understand fully how CMS defines medical necessity, and to develop further techniques to improve documentation and internal processes to capture additional revenue opportunities.
Resources: Ingenix, CPT EXPERT (2009)
AMA, CPT Assistant, (November 2008); Volume 18; Issue 11
AAPC, Evaluation and Management Specialty Study Guide, (2008)
Ingenix, Medicode-Complete Coding Tutor (2002)
http://www.cms.gov
April Borgstedt, CPC, CPC-I, CEMC, CCA, FSA, CMC, has 16 years of health care experience providing comprehensive practice analysis combined with educational solutions for compliance and revenue. She is a certified coding instructor with the American Academy of Professional Coders (AAPC), and she specializes in physician education, compliance and chart audits utilizing CMS guidelines. April is currently employed at Cancer Treatment Centers of America, an active member of the Pro Tulsa Chapter, and serves on the education committee at Tulsa Technology center promoting professional development. www.aapc.com
