megan72013@gmail.com
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- Temple, GA
Good Afternoon,
I’m looking for some advice from others who have worked through E/M coding disagreements with providers.
We have a few physicians in our practice who are very engaged in their coding and E/M level selection, which is great because they want to understand the guidelines and code accurately. The challenge is that we continue to have differences in interpretation despite multiple education sessions, guideline reviews, examples, and discussions.
One example is the AMA definition of an "undiagnosed new problem with uncertain prognosis." Some of our providers believe that any new injury or complaint without a definitive diagnosis automatically falls into this category and therefore supports moderate MDM. For example, a patient presents knee pain after an injury, no imaging is ordered, conservative treatment is recommended, and no additional workup is planned. Their position is that because there is no definitive diagnosis, it is an undiagnosed problem with uncertain prognosis.
Our coding team interprets the guidelines differently. We have always understood that "uncertain prognosis" implies a level of uncertainty about the outcome of the condition itself, not simply the absence of a definitive diagnosis. In the example above, if the condition is being managed conservatively and no additional workup is needed, we would not typically view that as meeting the definition of an undiagnosed new problem with uncertain prognosis. They are adding differential diagnosis codes and putting in the records that they are discussing surgery, but there is no true diagnosis for the pain.
We've reviewed AMA guidance, shared educational materials, and had several conversations, but we seem to keep coming back to the same points.
For those of you who have been in similar situations:
Thank you in advance for any insight you can share!
I’m looking for some advice from others who have worked through E/M coding disagreements with providers.
We have a few physicians in our practice who are very engaged in their coding and E/M level selection, which is great because they want to understand the guidelines and code accurately. The challenge is that we continue to have differences in interpretation despite multiple education sessions, guideline reviews, examples, and discussions.
One example is the AMA definition of an "undiagnosed new problem with uncertain prognosis." Some of our providers believe that any new injury or complaint without a definitive diagnosis automatically falls into this category and therefore supports moderate MDM. For example, a patient presents knee pain after an injury, no imaging is ordered, conservative treatment is recommended, and no additional workup is planned. Their position is that because there is no definitive diagnosis, it is an undiagnosed problem with uncertain prognosis.
Our coding team interprets the guidelines differently. We have always understood that "uncertain prognosis" implies a level of uncertainty about the outcome of the condition itself, not simply the absence of a definitive diagnosis. In the example above, if the condition is being managed conservatively and no additional workup is needed, we would not typically view that as meeting the definition of an undiagnosed new problem with uncertain prognosis. They are adding differential diagnosis codes and putting in the records that they are discussing surgery, but there is no true diagnosis for the pain.
We've reviewed AMA guidance, shared educational materials, and had several conversations, but we seem to keep coming back to the same points.
For those of you who have been in similar situations:
- How have you successfully aligned providers and coders on E/M interpretations?
- Are there any resources, articles, or AMA references that were particularly helpful?
- Have you found effective ways to move these discussions from "opinion versus opinion" to a more objective review of the guidelines?
Thank you in advance for any insight you can share!
