Look for Data Elements to Count Discussions Toward E/M
Question: I code for physicians who see inpatients and collaborate with other providers on patient care. How do I know what documentation is sufficient to count those discussions toward evaluation and management (E/M) levels? HEALTHCON Regional Attendee Answer: When you’re looking at documentation, you’re looking for an actual change occurring in the patient’s care, and the documentation should show that there’s an actual discussion of the case, said Leslie Prellwitz, director of CPT® Content Management & Development for the AMA, during a HEALTHCON Regional panel on E/M. When coding inpatient care, there’s sometimes a perception that if a patient exhibits a condition on the first day of care, it has a certain level of intensity and the intensity remains consistent throughout the day or stay, said Jaci J. Kipreos, COC, CPC, CDEO, CPMA, CRC, CPC-I, CEMC. Make sure you’re looking at what happened that day. For example, there may be a lot of medication management in the first couple of days, but then less may be happening in subsequent days. “Double-dipping is not allowed, so a good part of it is figuring out what happened today,” she said. If you have a chance to educate your providers on what you need as a coder, you could emphasize how helpful it is for the documentation to be specific. A good note might read: “Today, I consulted with another physician, and they told me to use x medication, so I prescribed it,” Kipreos said. Ultimately, you’re looking for data for the discussion for the provider, like the actual name of the physician and their respective specialty. Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC
