Health Information Management

Evaluation and management coding concerns continue

APCs Insider, January 11, 2013

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In a recent poll on JustCoding, we asked readers to vote on which area of coding gave them the most trouble. The winner, with 30% of the vote, was evaluation and management (E&M).

Part of the problem is that E&M coding is subjective. What one coder thinks is a level 4 visit, another coder could report as a level 3 or level 5. And they could both be correct based on how they interpret the guidelines and the documentation.
CMS has repeatedly said it will not create national E&M criteria, so each facility must create its own criteria. In 2008, CMS did offer the following guidelines for developing E&M level critieria.
A hospital's methodology should:
1. Follow the intent of the CPT codes reasonably relating the ­intensity of hospital resources to the levels of effort represented by the codes
2. Be based on hospital facility resources, not on physician resources
3. Be clear to facilitate accurate payments and be usable for compliance purposes and audits
4. Meet the HIPAA requirements
5. Only require documentation that is clinically necessary for patient care
6. Not facilitate upcoding or gaming
7. Be written or recorded, well documented and provide the ­basis for selection of a specific code
8. Be applied consistently across patients in the ED or clinic to which they apply
9.  Not change with great frequency
10. Be readily available for FI (or if applicable) MAC review
11. Result in codes that could be verified by other hospital staff, as well as outside sources
Notice that the guidelines do not say the codes must be distributed in any particular bell curve. Some facilities legitimately will report a large percentage of level 4 and 5 visits, while others may skew more to the level 2 or 3. It depends on what type of patients you see.
What you need to watch out for is a sudden change in where your visits are falling. If you see a sudden shift, review your criteria. You really should review them regularly (and CMS does not define “regularly”). Remember that review does not mean revise. Your guidelines should not change frequently (another term CMS does not define).
Review how the E&M levels are falling within certain departments. Are you seeing a spike in level 5 visits in the cardiology department? Are you seeing only level one visits in orthopedics?
Maybe you have new coders or your coders aren’t correctly applying your E&M guidelines. Training can solve that problem.
Don’t discount your electronic medical record (EMR) as a source of redistribution. Physicians may be documenting better (or worse) in the EMR and as a result, your visit level distribution has changed. That doesn’t mean the physicians have suddenly changed what they do during an E/M visit. It may mean that your coders can pick up more of the services the physicians have always provided, but maybe didn’t document well. So suddenly what used to be a level 2 visit is now a level 4. 
Even if your distribution hasn’t changed, you should still review your criteria, make sure they are accurate, and more importantly, that you can defend the coding results they produce.

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