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Coding E&M services with an Audit tool

  1. Question Coding E&M services with an Audit tool
    Medical Coding Books
    I have been asked to query the work process of this forum for coding E&M services.
    My staff codes inpatient attending and consultation charges. The notes are all on line, so there is no paper involved with their coding right now.
    What I would like to know is how do you code from an EMR ?? Do you use a paper audit tool to level the note ??

    Thank you for your input !

  2. #2
    Greeley, Colorado
    I use a paper audit tool.
    Lisa Bledsoe, CPC, CPMA

  3. #3
    Milwaukee WI
    Default Question asked on another forum
    This question has been asked recently. Try to search for it ... I know it's been sometime in the past couple of weeks.

    F Tessa Bartels, CPC, CEMC

  4. Default
    Yes, I saw that post. I guess what I'm looking for is more of, how many E&M coders are filling out a paper audit tool in their everyday coding and how many are reading the notes and jotting down the key elements to determine the level?
    Any input on this would be greatly appreciated.

  5. #5
    Grand Rapids, MI
    We use Intelicode for doing an E/M. We only do this if a level has been forgotten by the physician or if we question their level. Our charts are all electronic but we have not yet moved totally away from paper encounters. We will begin to implement that beginning next month with one or two of our docs. Hope that helps.

  6. #6
    I print the report from the EMR and audit directly onto the printed copy. I have to be very careful to include all the relevant records for the particular service. I keep an audit worksheet available for reference purposes, but don't fill out an audit worksheet for each record being audited. Having the actual record with my markups is extremely helpful for any potential questions related to the audit findings.
    Jenny Berkshire, CPC, CEMC, CGIC

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