Revenue Cycle Insider

Question: Our practice sees many student athletes with sprains and other sports-related injuries. Even though these conditions may appear straightforward, can they support a higher evaluation and management (E/M) level? Do you have any tips as to what should be documented to accurately reflect the higher complexity of a given encounter?

Arizona Subscriber

Answer: Yes, you can absolutely support a higher level of E/M based on the notes. Although sprains and other sports injuries are often categorized as acute, uncomplicated injuries, that does not automatically mean every encounter should be considered low complexity. The level of service should reflect the specific circumstances of the patient, the provider’s evaluation of the injury, and the risks discussed with the patient during the visit. If the documentation makes the injury look like a simple sprain, payers are more likely to view it that way as well. Thorough documentation is essential to support the complexity of the encounter.

For example, documentation that simply states: “Right ankle sprain. Recommended rest, ice, compression, and elevation” may support only a straightforward assessment and a lower level of E/M or medical decision making (MDM).

On the other hand, documentation that clearly demonstrates the work performed and the additional factors considered supports a higher level of MDM and therefore a higher level of E/M. Consider this detailed note: “Patient is a varsity soccer player who sustained a right ankle injury during a tournament weekend. Exam reveals swelling, tenderness, and instability with weight-bearing. Discussed risk of recurrent injury and long-term instability if return-to-play occurs too soon. Reviewed treatment options, activity restrictions, rehabilitation plan, and expected recovery timeline with patient and parent. Parent participated in history and treatment planning. Follow-up arranged to assess healing and readiness for return to sports.”

Other details that may help demonstrate additional complexity include the following:

• The athlete’s level of participation and risk of reinjury
• Findings that raise concern for instability resulting in a more significant injury
• Discussions regarding return-to-play decisions
• Preventive measures to reduce future injuries
• Conversations with parents or guardians who provide history or participate in decision making
• Referrals to athletic trainers, sports medicine physicians, or orthopedic specialists when appropriate
• The provider’s rationale for treatment and monitoring decisions

Remember: Payers evaluate the claim based on what is documented, not what may have occurred but was accidentally left out of the record. Clearly capturing the provider’s assessment, management decisions, risk discussions, and patient-specific circumstances helps support the appropriate — and elevated — E/M level.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC