Question Changing E/M Levels to meet criteria


Best answers
I am question after a physicians give their e/m codes (example : 99223) for the medical coder to code and while the medical coder audits the e/m they find that the e/m code does not meet criteria for the e/m code ( example 99223) by any of the 3 components . Can the medical coder inform the physicians of what is missing and the physicians go back and do an addendum to meet the criteria? If so is there a time frame the physician is able to change example pt seen but medical coder does audit 3 weeks later?


True Blue
Beaverton OR
Best answers
When I see or her of providers that want to fit their documentation to satisfy certain codes, I get concerned about the intent and purpose of their documentation. The role of a coder is not to lead the providers in their coding, but supply coding guidelines and regulations when it comes to coding. There is a tendency, and this is especially true in EHRs, to have bloated documentation just to hit certain E/M level criteria. This generally does not support medical necessity, and as you read the CMS E/M guidelines, you will find that medical necessity will always trump any audit tool or point system.

If the physician truly forgot to include additional information that was occuring during the time of service, then he/she can amend the documentation. Depending on the patient's payer, they might have different timeline rules, but the general rule of thumb is to amend ASAP, with proper attestation and reason for the amendment. Otherwise the amendment might come into question when the record is audited by CMS or the payer.

Hope this helps you!

CMS E/M guidelines


True Blue
Best answers
I agree, the coder should not lead the provider. It is not considered a compliant practice to query the provider for additional documentation to meet a code level. Queries and amendments to documentation should be solely for the purpose of clarification and/or correction of clinical information. If your practice was audited and found that amendments to documentation were made in order to inflate code levels, the auditors could disallow that information.