Just like math teachers who require students to show their work so they can see how the student reached their answer, providers are also required to "show their work" through the documentation process in the medical record. By the time a provider has reviewed the patient's subjective complaints (i.e., patient's medical history), performed an examination, and reviewed any test results, they have already formulated a working diagnosis and understand the associated risks of treatment or failure to treat that the patient will face.
In this process, the provider is sorting through subjective and objective data to determine not only the diagnosis, or whether there is even enough information to do so without additional testing, but also the level of severity associated with it.
Questions providers may be asking include:
- Can the patient wait for additional testing and results before receiving treatment?
- What kind of treatment is required?
- Are more conservative measures appropriate (e.g., rest, over-the-counter medications) or do they require a prescription medication to recover?
- If a prescription is required, what are the risks associated with it and is it contraindicated with any other prescription medications or supplements the patient is already taking to treat another condition?
- What are the other conditions (chronic or co-morbid) the patient has and how might the recommended treatment for the current problem exacerbate them?
- Will the patient require a minor, major, or emergency surgical procedure and if so, what risks, if any, are associated with the recommended procedure?
- Is there a risk to an organ system, bodily function, or even the patient's life if they go without treatment (e.g., DNR, palliative care) or if they choose to complete the treatment?
A provider who is adept at documenting the required criteria to support medical decisions and medical necessity and to support the level of E/M service reported is a coveted asset. We have all seen providers who can quickly evaluate, assess, diagnose, and determine treatment for a patient with a problem of moderate complexity, even at times a high complexity problem. So why would you report based on time when MDM may be a better outcome? Although time, when documented correctly, can easily support a level of service,improper or incomplete documentation can result in attempted recoupment of reimbursement.
Payers may be looking at issues such as:
- Whether the provider documented in a Start/Stop or Total Time fashion (and whether that method meets the payer's rules)
- Whether documented time is supported with a detailed enough description of "qualifying activities"
- Whether the time is specific to only the physician/QHP or if clinical staff time is also included
- Whether any lab or imaging results the provider discussed with the patient were correctly excluded when the provider was billing for those services separately
Consider documenting the time for all your patient interactions reported with 99202-99215. Remember, these, and only these, services allow you to count both face-to-face and non-face-to-face time spent by the physician/QHP, while all other E/M services do not. Do not mix up your guidelines. When tracking time but documenting to support MDM, you will quickly be able to determine which types of conditions, injuries, or problems are best reported with time and which are best suited to reporting by MDM.
Whichever way you choose to document to support the E/M level reported, at innoviHealth we have created an E/M Quick Reference Card to help you meet the specific requirements for each code reported. This card is a great tool to teach physicians/QHPs how to document to support the various levels of MDM or time, and is extremely useful in explaining audit findings when evaluating claims and supporting documentation, especially related to E/M services (99202-99215).
by Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content