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Dispel 4 common E/M coding myths to enhance core coding compliance

Do away with preconceived notions you may have about E/M coding, such as the required number of elements you must document for established patients, to lower your audit risk and get those frequently issued claims through the door.

Office visit claims with codes for new patients (9920199205) and established patients (9921199215) are in the crosshairs of most payers because of their outsized contributions to overall Medicare spending and because the.y’re “identified as [services] with a high error rate by payers,” says Doris Branker, president of practice management consulting firm DB Healthcare Consulting in Fort Lauderdale, Fla.

Practices can fall into a pattern of risky behavior if they don’t hew closely to tried-and-true coding practices, warns Branker, who led a DecisionHealth E/M coding webinar on May 12. Avoid that trap by dashing common misconceptions.

Myth: A patient who’s new to your office is always a new patient. This is a common issue, especially among larger groups with multiple physicians of the same specialty, observes Branker. The correct code choice does not come down to whether this is the patient’s first visit to your office — but whether you’ve seen the patient before. “If you’ve had a face-to-face encounter with the patient irrespective of the setting, [then] they’re assigned to you,” explains Branker.

For instance, let’s say Dr. Smith, a cardiologist, goes into the hospital on a Tuesday to see a new patient, Bill Jones. After Bill Jones is discharged, he visits Dr. Smith’s practice the next Monday for a follow-up appointment. In this case, because the patient saw the doctor within the previous three years, he met the requirements of an established patient, and the doctor would have to choose an established-patient code.

You’ll earn fewer dollars billing 99213 ($73.40, national, non-facility) rather than new-patient code 99203 ($108.85, national, non-facility), but the $73.40 is far better than a denied claim and the time and resources you’ll need to resubmit.

Remember that the established-patient rule applies to all of the providers within the same specialty at your practice, reminds Branker. That means if fellow cardiologist Dr. Samuels sees Bill Jones after Dr. Smith’s initial hospital encounter, you still have to bill an established-patient code.

The rule, however, does not apply to providers of different specialties. If an orthopedist sees Bill Jones and then Jones returns for a podiatrist appointment, the new-patient codes apply to both visits. “I could bill new patient encounters because they were not the same specialty even if they’re in the same group,” says Branker.

Myth: You have to select one E/M guideline over another. You can look to the 1995 or 1997 E/M guidelines to help you document correctly, but you don’t have to make an ironclad choice, says Branker. The two sets of guidelines contain some differences, mainly pertaining to the exam documentation. But you won’t score points with auditors by choosing one set of guidelines and sticking to it because “auditors do not know which one you use,” says Branker, who urges you to use the set most beneficial to your setting. Auditors, for their part, may look to both sets of guidelines as a blueprint because CMS allows portions of each. “For services performed on or after Sept. 10, 2013, physicians may use the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 guidelines to document an evaluation and management service,” states a frequently asked question CMS issued in 2013.

Myth: You’re allowed to document only two of the three E/M elements for established patients. Branker warns that there’s a misconception that you’re required to document only two of the three available elements — history, exam and medical decision-making — for established-patient office codes. While CPT uses language that states it “requires at least two of these three key components,” the interpretation that you can bypass documenting one of the elements won’t fly.

Official Medicare coding guidelines state that “you have to document three,” she warns. While you may have encountered CPT guidance suggesting otherwise, “I don’t think at the end of the day you’ll be able to use that CPT article” in response to your Medicare administrative contractors (MACs) that may take issue with just two elements recorded, Branker says.

Myth: A low-risk diagnosis means you can’t code to higher-level services. Don’t think that certain conditions are ruled out from higher-level E/M codes. “If my medical decision-making is low and I did a detailed history and exam, I can support a level 4,” explains Branker.

For example, if the presenting problem is a stable chronic illness, such as controlled hypertension, combined with a case of allergic rhinitis — which, together, would be considered a low level of risk — you’re not excluded from claiming a level 3 or 4 E/M code — provided, of course, your history and exam elements meet the threshold for those higher-level codes.

“Internal medicine patients with multiple chronic conditions” are a good example of the dynamics involved in this type of scenario because they often require extensive history and exams, Branker explains. Just make sure your other elements make the grade.

Resource: CMS FAQ