Recorded at HEALTHCON 2025 in Orlando, FL
The video discusses the complexities of documentation and billing in healthcare, emphasizing the importance of accurate records for patient assessments and coding. It highlights the challenges faced by providers, especially in high-risk situations, and the need for clear documentation to support billing claims.
The conversation also touches on telehealth codes, reimbursement issues, and the significance of patient discussions in the documentation process. Additionally, it addresses the discrepancies in diagnosis codes that can lead to payment denials and the impact of new policies on billing practices.
Why daily narrative matters in E/M
Clinicians often “retell the story” from day one even though they are documenting day five. When notes recycle prior plans without clearly stating what changed today, auditors can’t distinguish past thoughts from current or new thoughts.
For inpatient subsequent visits, documentation should reflect day-to-day evolution: what was initiated previously, what was assessed today, and any adjustments or affirmations (“we will continue X”).
Practical fix: carry forward prior context sparingly, then pivot to “Today’s interval history/assessment/plan” that shows current condition, actions, and rationale. This aligns E/M selection to the actual work of the day rather than historical narrative.
If you’re billing an E/M every day, it shouldn’t look like you’re doing the same work every day. Document the fluctuation.
Case 1: Copy-forward vs. “what you did today”
Panelists noted frequent gaps between what was thought or done and what was written. Result: undercoding (e.g., defaulting to level 3) because the note lacks “meat” on decisions, data review, and risk.
Auditors want explicit statements: what you considered, what you chose, and why it matters today.
Tip: Use a structured close — “On today’s encounter…” followed by interval changes, decisions, and risk discussion — to convert implicit clinical reasoning into visible E/M elements.
Case 2: Preventive vs. GYN-only — Avoid the “comprehensive” trap
A patient seen by OB/GYN for an “annual GYN exam” was billed as preventive medicine + problem-oriented E/M with pelvic exam.
Panelists struggled to find documentation meeting preventive medicine (9939x) expectations: age/sex-appropriate comprehensive evaluation (beyond gynecologic system), anticipatory guidance, and counseling on broadly recommended screenings (e.g., colon cancer at 45).
The note supported a GYN-focused visit, not a full-body, age-appropriate preventive service.
Practical paths:
Bill a problem-oriented E/M (possibly time-based if counseling dominates), plus separately report performed procedures/tests when appropriate.
Document why labs/imaging/meds are ordered and status of any chronic conditions if using a separate E/M with modifier-25.
Broader issue: “annual exam” means different things to different specialties. Dermatology “skin checks” and GYN “annuals” can be clinically valid, but code selection must match code descriptors, not payer habit or patient expectation.
Preventive codes expect whole-person scope and anticipatory guidance; a single-system “annual” usually does not qualify.
Case 3: High-risk counseling (oncology) and the power of time
A high-risk oncology clinic note showed extensive discussion of surgical options but no diagnosis recorded and no time documented.
Without a diagnosis, MDM leveling stalls; without time, rich counseling can’t support a higher time-based level.
Distinguish generic informed-consent risks from patient-specific risk used in E/M MDM. If discussing prophylactic surgery due to BRCA or similar risk, state the clinical status (e.g., high-risk, no confirmed cancer) and decision context.
Best practice: when the visit is counseling-heavy, document total time and how it was spent (no itemized seconds required — just clinically meaningful buckets). This often more accurately captures effort than MDM for anticipatory counseling and shared decision-making.
If the encounter is essentially complex counseling, time-based coding may be the cleanest, fairest path — but only if time is documented.
Case 4: Urgent care → ER: “why the escalation?”
Common pattern: “Sent to ER due to multiple comorbidities” without listing any comorbidities or the clinical reason for escalation.
Auditors need why ER is necessary today: capability gap (e.g., IV fluids, imaging), specific concern (e.g., sepsis risk, dehydration), and any coordination (who was called, when, and what was communicated).
Absent that, risk defaults low-to-moderate; many such notes top out at level 3 despite real clinical urgency.
To claim higher risk, show your work: name comorbidities, suspected complications, required resources, and specific handoff details.
Case 5: Fever isn’t automatically “systemic”
Many equate fever with “acute illness with systemic symptoms” (moderate risk). Panelists cautioned against “bright shiny object” bias.
It’s not the fever alone; it’s the overall clinical picture and morbidity without treatment.
Example: otitis media can be level 4 only when complexity justifies it (e.g., recurrences, ENT referral/surgery decisions). Otherwise, it’s often uncomplicated.
Don’t anchor on a single symptom. Level to the problem(s), data, and patient-specific risk — not a trigger word.
Q&A highlights you can apply tomorrow
Prescription drug management when patient declines
Yes, recommending a prescription can count — if the conversation is documented: intent, risks/benefits, patient’s reasons for declining, and plan B. You don’t need dose/frequency if it won’t be taken, but capture the decision-making.
Toxicity monitoring (high risk)
To support high-risk drug toxicity monitoring, document: what drug, what toxicity, what tests, why, and monitoring cadence (typically at least quarterly). Black-box warning alone ≠ automatic high-risk; show the monitoring plan.
Annual wellness + problem E/M with -25
For Medicare AWV, problems are not part of the AWV. If you evaluate/manage a condition (status, plan, labs, med changes), a separate E/M with -25 may be appropriate — if the documentation stands on its own once AWV elements are removed.
Split/shared attestations
If the billing provider attests to owning and approving the MDM, they needn’t re-document every detail; the attestation makes them responsible for the content and risk.
Addendums for time
Adding time after the fact just to upcode is risky. If time was omitted, an addendum used appropriately and promptly for a genuine omission might help, but many auditors won’t accept late “billing-only” addenda. Build strong time documentation habits instead.
Time vs. complexity — which is “better”?
Use either, encounter by encounter. Specialties vary; counseling-heavy visits (pain, oncology, complex decisions) often level more accurately by time — provided you document total time and how it was spent.
Pediatric / nonverbal patients and telehealth
Real-world issue: caregiver-only telehealth when the patient cannot participate. Guidance is evolving; where allowed, document the independent historian role, the clinical decisions, and why patient presence isn’t feasible. Watch for CPT® Assistant/payer updates.
Telehealth codes vs. CMS and parity
AMA created telehealth-native codes to reflect modern delivery and resource use. CMS chose to keep traditional E/M + modifiers, citing parity/payment and legislative constraints. Commercial payer adoption varies; follow payer policy, and be ready to map equivalents for secondary billing.
Wound care + E/M with debridement
E/M may be separately billable only if there’s a significant, separately identifiable evaluation beyond the inherent pre/post work of the procedure (e.g., new infection evaluation with targeted management). Documentation decides.
Post-op/global and “boarding” inpatients
Patients medically ready but awaiting placement can still have billable daily E/M if there’s ongoing assessment/management. Often low level, but still billable if work is documented.
Big takeaways
Document today’s thinking and decisions. Explicitly separate past, current, and new thoughts.
Match the code to the service — not habit, payer anecdotes, or patient expectations.
When in doubt, time can save the day — but only if you document it.
Risk is patient-specific, not boilerplate consent language.
Telehealth remains payer-specific. Know the rules, keep a crosswalk, and explain your coding choices in appeals.