Advanced E/M: Fill in the Paperwork’s Shortcomings

By Bill Dacey, MHA, MBA, CPC
Evaluation and management (E/M) is a struggle for many coders. The E/M coding system can be very confusing and difficult. Here are some observations and direction to help you find the right E/M coding path.

Let EMRs Work for You

As electronic health records (EHRs) or electronic medical records (EMRs) become more commonplace in providers’ offices, it’s interesting to see what unfavorable documentation conventions and other aspects of practice management are cemented along with the good.
There are a host of good reasons to adopt EMRs, as these tools are designed to make a practice more efficient, accurate, secure, etc. However, there are nagging elements that seem to tag along as well.
In the paper chart documentation of history of present illness (HPI) we see the phrases “here for follow up,” “here for refills,” and “here for labs.” That’s not really why the patient is there; however, it’s what the chart suggests. The patient is actually there to take care of the problem for which the laboratory work and medication is being evaluated and managed. The note should always say so.
But now, we see these same conventions passed along to the EMR, dressed up to look more robust. For example, “Patient presents for evaluation and management of chronic medical problems.” Sometimes, there are notes that reflect the problem list, and/or medical list. Providing a list of problems isn’t an HPI either—it’s just a list. The medical record should prompt the provider to describe in detail relevant information about chronic status. The chart should provide a space or suggestions as to the relevant review of systems (ROS) information to go with the HPI info.
Ideally, the goal of the electronic format should be to help physicians supply the real data needed, not to make an electronic version of the old, insufficient paper chart.
In a perfect world, EMR systems should be used to accommodate provider idiosyncracies and individual styles. If your provider takes 20 minutes for 15 minute appointments, let the system work around the reality. Let the EMR system schedule two consultations and a new patient visit according to the amount of time the physician usually needs, and use the intelligence of a computer system.
Physicians are best managed when they don’t realize they are being managed. Do the managing with the documentation, the codes, and the schedules. Allow the system to shape the encounter and integrate the elements needed for successful patient encounters, coding, documentation, and billing.

Documentation is Key

Audits, reviews, and regulatory functions require codes to have documentation support in the chart. Unfortunately, there are documentation elements that providers naturally miss, as the one-size-fits-all rules don’t fit all encounters or specialties neatly. The history and exam require particular documentation, but deciphering what the most important part is can be tricky. What are the key elements you hear about?
If physician pick their code based mostly on medical decision-making (MDM), it’s hard for them to know how to document it or what the payers are looking for.
If they look at the table of risk or any of the tools used to determine MDM, a common theme emerges. To determine the level of work and its subsequent documentation, the provider must distinguish how many problems are being evaluated or managed, what the status of those problems are, and what the management is.
Lay out each problem like this: diagnoses (Dx), status, treatment (Tx), and medication (Rx). Don’t give a list of problems under A), and a short list of medical changes under P) if they aren’t linked to one another. Each problem should have a clear link between Dx, status, and Rx/Tx.
When using CPT® code 99212 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A problem focused history; A problem focused examination; Straightforward medical decision making, state the problem and its treatment or lack of.
For coding 99213 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity., do as above. For either a single acute problem or two stable chronics, show the treatment. Don’t say “continue same,” “refill all,” or “follow-up 3 mos.”
When using 99214 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: A detailed history; A detailed examination; Medical decision making of moderate complexity., documenting Dx, Status, Tx/Rx is very important as to follow Medicare guidelines. Make sure you know how to document a chronic disease follow-up visit. Lay out the three stable chronic problems, their status, and management. The status problem in the A/P area should mirror the HPI where in the same up-front manner.
There is an easy symmetry that can be achieved here:
1) Hypertension (HTN), pressures running in the 130’s, no dizziness, salt intake down
2) Dyslipidemia, exercises daily, still taking red rice yeast extract, no muscle aches
3) Chronic obstructive pulmonary disease (COPD), using inhalers PRN, wheeze reduced w/recent jogging
Match this up with the A/P area:
1) HTN, stable, continue (med name) Dyslipidemia, continue exercise and supplements, labs today
COPD, continue inhalers as needed and (name Med)
The management is clear. In these cases, the whole level and the nature of the visit is determined at a glance. These are the most common uses for code 99214.

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