Health Information Management

Tip: Know the documentation essentials for E/M coding

APCs Insider, August 12, 2011

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A thorough understanding of 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. Documentation for E/M services must include:

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

When determining E/M accuracy, begin by asking which level of service the provider selected, which level the provider should have selected, and whether the provider or coder selected the appropriate diagnosis codes.

The steps that auditors need to take when conducting an E/M documentation audit include the following:

  • Conduct 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 Services, A Step-By-Step Guide to Accurate Coding, Reimbursement, and Compliance, Second Edition. For more information or to order a copy of the book, visit HCPro’s Healthcare Marketplace.

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