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Providers choosing E&M codes

  1. Default Providers choosing E&M codes
    Medical Coding Books
    We are just learning a new ehr system. In the past, providers mark what charge they believe on the superbill, however it has always been up to our coders to verify the note & code it ourselves coming up with what CPT we think. And we change if needed.
    Our ehr system is requiring that providers choose & put an E&M code on to the actual office visit note when they dictate/scribe their office note.
    It will still come to coders to verify but if we decide they've over-coded or under-coded we then have to ask them to addendum their note to change the code.
    Is anyone else doing this? We have been told by our ehr vendor that this is now a requirement due to meaningful use?
    Seems to me that we are going to be asking for a lot of addendums as most of our providers are not up to date on billing/coding requirements because they have us to do that for them.
    Just wondering if anyone else has heard this or is having issues? Thank you for your time!

  2. Default Ehr
    This sounds like an EHR that should be improving efficiency creating unnecessary work for you. My experience as I'm sure yours is that providers do a very mixed job in terms of E&M, some are pretty good, others not so good. And of course there are those who pretty much use the same level all the time. Yours might be better than that, but I'm sure you are changing levels a fair amount of the time based on the documentation that you receive.

    So I'm not certain what the providers would be addending if you are simply disagreeing with their Level, and coding based on the documentation in the record? Does your EHR vendor want them to make a note about changing the level? And I'm not certain where the meaningful use tie in occurs. I would ask for a specific citation from your EHR personnel.

    I think requiring addenda will create processing delays and roadblocks since anytime a record is returned for revision that happens. That process can also create compliance issues in terms of timing of the addenda etc. Would your organization consider discontinuing the physicians entering a level? This might be more work for you, but it would put coding where it belongs.

    jim s.

  3. Default
    Our EHR chooses the E/M code for us and sends it through to me. I then have to verify it and change it based on the notes.

    Our EHR uses templates though. The code is chosen and stored there, not on the actual medical record document that comes through at the end. The doctors do not need to change the template as we do our coding only off of the final document.

    We are a derm office, so it may be slightly different, but I can't think of any MU requirement like that. It may be due to another MU requirement that is linked somehow in your EHR. For example, we can no longer customize our visit types (office visit, surgery, mohs, and so on) because they are linked to how our EHR calculates our denominator. THAT could be what they are talking about, but since you don't have an E/M code for every visit (at least we don't)...ours calculates based on our selection of the visit.

    You may want to clarify that with your EHR vendor. If it is a denominator issue, that isn't calculated based on how many 99212s you have for example, just the fact it was a qualified visit.

    April Sue

  4. #4
    Baton Rouge
    It sounds like our EMR works similar to yours, Sadie. The charge, along with any tests/procedures the providers order, show up at the bottom of the note. However, (and I have been involved in the MU development/implementation/attestation process in our clinic for a few years now) I don't ever remember coming across anything stating that MU requires you to append the document if you are changing the level billed. IMO, the charge doesn't need to show up there. BUT as long as the document supports what is actually billed out on the claim, there shouldn't be any issues. Now, for all the charges you recommend changes to...if there are any providers that have patterns of what they are doing wrong, use that as educational opportunities. But for them to have to append for every single change you make sounds like a huge time-waster!!

    Meagan Strauss, CPC, CEMC
    Coding Coordinator
    The NeuroMedical Center
    Baton Rouge, LA

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