Monthly Archives: June 2014

5 Focus Areas to Improve E/M Documentation and Reimbursement

5 Focus Areas to Improve E/M Documentation and Reimbursement

Evaluation and Management (E/M) services comprise a significant portion of most providers’ billable services.  It is therefore important to ensure that diagnostic codes are optimal and services are documented carefully. This ultimately affects reimbursement.

Here are five common problem areas to watch for.

1. Legibility

  • Two fundamental rules are “Not documented, not done,” and “You can’t code what you can’t read.
  • The CMS guidelines state that all entries in the medical record must be legible.
  • Orders, progress notes, nursing notes, or other entries in the medical record that are not legible may be misread or misinterpreted and may lead to medical errors or other adverse patient events.
  • The use of EHR to document patient encounter solves this problem.

2. Documenting Orders

  • CMS states that the physician who treats a patient for a specific medical problem and who uses the results in the management of the patient’s specific medical problem must request the diagnostic test for a beneficiary.
  • Tests not ordered by the treating physician/practitioner are not reasonable and necessary.
  • The provider’s office may create a template for commonly ordered diagnostic tests, however, the request must be validated with the ordering provider’s signature.

3. The Provider Must Record the HPI

  • The three key components of an E/M service are history, exam, and medical decision-making.
  • History is composed of the chief complaint (CC), history of present illness (HPI), review of systems (ROS) and past, family and social history (PFSH).
  • The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient, however, the physician must notate that the information was reviewed.

4. Consider Patient Status and All Relevant Key Components

  • When selecting a level of care for a new patient, use the three key components for proper selection of codes.
  • Established patient require two of the three key components for accurate coding.
  • Providers should always document the nature of the presenting problem, and select the code that appropriately represent the services rendered.

5. Diagnoses

  • Diagnosis and procedure codes should be reported to the highest number of digits available (highest degree of certainty) for the encounter/visit
  • Code all documented conditions that coexist at the time of the encounter/visit that affects patient care, treatment or management
  • Always sequence diagnoses in the proper order, beginning with the problem/condition chiefly responsible for the patient encounter, followed by secondary problems/conditions relevant to the services rendered and not already described by the primary diagnosis.