Base E/M Code Assignment on the Level of MDM to Ensure Accurate Reporting
Published on Fri Oct 01, 1999
When most ED physicians look at a medical chart, they use a top down approach: take the history, perform the examination and then document the medical decision-making (MDM) they used to arrive at a treatment decision.
However, coders and billing companies in charge of reporting services by emergency physicians should understand that Medicare auditors and most other payers look at charts very differently, advises John Turner, MD, FACEP, medical director of documentation and coding compliance for TeamHealth Inc., an emergency physician staffing company based in Knoxville, TN. Understanding how to code a chart from the bottom up can ensure that emergency evaluation and management (E/M) services are reported accurately and can take much of the complication and worry out of reporting these services.
Most auditors will try to figure out the overall value of the chart first, advises Turner. When you think about it, when a patient goes to the emergency room for treatment, they dont really care what is written in the medical history or what type of exam is performed. The only thing they really care about is, they were seen by the physician, he came up with a diagnosis, performed any tests that were necessary, gave them medication, and got them out the door. What they are paying for is the medical decision-making process that the doctor goes through. That is the real worth of the chart. Medicare knows this, and that is what they look for first.
What is Bottom Up Auditing?
Medicare auditors and most other payers, Turner contends, will look at a patients chart and first determine the level of medical decision-making. They use that level as the basis for the level at which the chart most likely will be coded. Then, the auditor will go back up to the history obtained and the exam performed and check the documentation to determine whether it supports the level indicated by the decision-making involved.
A Medicare auditor will look at a chart and look first at the bottom, they will put all of the medical decision-making data into their table (See previous article on E/M code 99282 in the September issue of ECA on page 67.) and come up with a value for that level, for example a Level 4. Then, they take that Level 4 and go to the top of the chart to the history and physical to see if the documentation supports a Level 4. If the documentation isnt there, they downcode it.
Using This Method to Your Advantage
Coders can learn to look at an emergency physicians charts in the same way and educate the physician about where documentation might need to be improved to consistently bill an appropriate level for E/M services.
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