Evaluation and management codes figure at the top of the list of services that medical practices tend to miscode most often. These codes are used almost everywhere and there are very specific guidelines around these codes. And getting the right level of E/M service every time for each patient can be challenging.
For example: Auditors have for long had their eyes on E/M coding and incident-to billing – and the scenario has not changed much even now. One would expect practices to be more watchful with E/M coding; but in actuality, error rates have actually gone up, the latest report from CERT suggests.
According to the 2014 Medicare Fee-for-Service improper payment rate went up to 12.7 percent in 2015, worse than the error rates logged in year 2012 and 2013.
But you can safeguard your organization from potential audits and penalties by conducting internal audits before the payers do. Any organization/practice that’s not conducting self-audits at least once a year is living life on the edge as self-audits can help you identify coding issues before they take the form of a complete crises.
How to conduct self-audits
Example: Physician is performing a level-four established patient office E/M (99214); but he is only documenting a level-three service (99213). Here, a self-audit would help the practice locate the problem and provide education to the physician. When medically appropriate, the service needs to be documented well at the 99214 level or correctly coded at the 99213 level. In both cases, the selection of code was incorrect.
How to self-audit E/M coding
This involves reviewing and vetting a lot of documentation. The encounter notes on your claims must reflect all required elements for the E/M level. To put it in simpler terms, during the self-audit review of E/M charts, ensure the documentation for history, exam, and medical decision-making support the level of E/M you are coding. While reviewing claims, you can follow either the 1995 or 1997 E/M documentation guidelines – but you must make it a point to follow them to the letter.
Moreover, watch out for Evaluation and Management Coding: examples where you witness an E/M coding pattern that doesn’t line up with documentation. E/M coding basically involves these two issues: One, coding at a particular level for patients with certain issues and secondly reporting an E/M service every time a patient presents for a procedure.
Get more insight on ways to conduct self-audits and understand the intricacies of E/M coding and pitfalls using Evaluation and Management Coding Handbook of The Coding Institute.