I really need some help with coding E/M visits I have started a project but just can not get the em. I have the audit tool for 1995 because that is what the facility use. I will appreciate any help I can get I am a great coder but for some reason this e/m is not clicking. I do not know what else to do or how to get a better understanding of the e/m when looking at a patient chart. I really need to keep my job and will take all the help that I can get. I also started back looking through my coding books but it is just not coming together... Please help me conquer this..
I'm a biller, not a coder- yet. But my advise would be to get a cheat sheet from Ingenix that shows a break down (a chart system) of each catagory of codes with-in the E/M code set that identifies the requirements for each code. Doctors use them and so can you. Hope this is helpful.
My suggestion would be to make a copies of a few notes so that you can mark them up. Take your audit tool and go through the notes marking just the HPI elements (you only need four for a comprhensive so don't go crazy trying to find every single element). Then with a differnet color go through and mark the ROS, history and exam (all with different colors). Once you have done this then look at the MDM, how many problmes did the patient present with, are they chronic or new, is this a new patient to the provider? What types of test did the provider review or order, did he have to obtain info form other sources? Then the risk, I find this is the most subjective part of the MDM, bur use the Table of Risk on the audit tool and that should help.
Once all of the other things are done use your audit tool to determine your E/M code. For New patients or Consults 3 of the elements HPI, Eam and MDM must meet or exceed the requirements, for established you only need two out of three. It will take awhile and you will be slow at first, but the more you practice the easier it will become. I suggest different colors for each element because that will help them to stand out to you. Also each doing each element separately will help you learn to break down the notes since they are not always arranged like we would want them. Hope this is helpful.
I've been doing E?M coding since 1998. Send me a copy of your audit tool; I may have one that can better help you. firstname.lastname@example.org