Corporate Compliance

Tip: Perform documentation audit when reviewing E/M coding

Healthcare Auditing Weekly, March 24, 2009

A thorough understanding of evaluation and management (E/M) coding begins with documentation. If it’s not documented, it didn’t happen. Documentation is crucial to any area of coding and is especially important when determining an E/M level of service. Documentation for E/M services must include:

  • Place of service (i.e. office, outpatient hospital, nursing home, inpatient, etc.)
  • Patient status (i.e. new patient versus established patient)
  • Type of service (i.e. consultation or office visit)

To determine E/M accuracy, begin by asking what level of service the provider chose versus what level of service he or she should have chosen and whether the provider/coder selected the appropriate diagnosis codes.

There are several steps that an auditor will need to take when performing an E/M documentation audit, including the following:

  • Perform a risk assessment to identify high-risk areas and other elements that can affect risk
  • Design a sample size and payer mix for tracked data
  • Trend information to compare results internally, by region, and by specialty
  • Develop a compliance plan to relay information to providers and establish ongoing monitoring

This tip was adapted from Auditing Evaluation and Management Coding. For more information about the book or to order your copy, visit the HCMarketplace.

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