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March 2018

Coding Corner: Medical Necessity in E/M Code Selection
By Nena Scott, MSEd, RHIA, CCS, CCS-P, CCDS
For The Record
Vol. 30 No. 3 P. 6

Medical record documentation is the vehicle to record medical decision making and determine the correct evaluation and management (E/M) codes for physician-patient encounters. As of January 2016, it is estimated that 95% of primary care providers had installed EHRs to help capture physician documentation, record how medical decisions were made, justify medical necessity, and select proper E/M codes.

Widespread use of EHRs in the practice setting would seemingly ensure correct physician documentation is present and E/M codes are assigned. However, in day-to-day practice, this is not the case. For example, the ability for providers to cut and paste information from one encounter to the next has complicated the process.

This article highlights the role of medical record documentation to ensure correct E/M code assignment, record proper medical decision making, and justify medical necessity for physician practice billing claims.

Breaking Down E/M Codes
E/M codes designate the level of care for each patient-physician encounter. Each of the five levels of care has a designated CPT code. The following key components are used to document additional levels of complexity:

• History. Includes four elements: chief complaint, history of present illness, review of systems, and medical, family, and social histories. Levels of complexity include problem focused, expanded problem focused, detailed, and comprehensive.

• Physical exam. Includes the same levels of complexity as history: problem-focused, expanded problem-focused, detailed, and comprehensive.

• Medical decision making. Includes four levels: straightforward, low complexity, moderate complexity, and high complexity.

Medical necessity is determined by the documentation of the requirements listed above. For new patients, the level of care must meet or exceed the level of service requirements within the three key components. For established patients, the level of care must meet or exceed the level of service requirements within at least two key components.

Some providers have the mistaken impression that more documentation warrants a higher level of service. That is not the case. The overarching criteria required for the justification of a higher level of service is medical necessity.

The Relationship Between Volume and Level of Service
EHRs typically feature templates with check-off boxes that physicians use to help document the care they provide. However, checking a box doesn't satisfy key component requirements.

The challenge for providers is to document the elements pertinent to the current issue without copying irrelevant information. If a test is ordered or a medication prescribed, a provider must document the rationale for doing so. The documentation must explain why the medical decision was made in order to establish medical necessity for the intervention.

For example, if a provider notes in the record that a test was ordered based on the patient's specific symptoms and medication was prescribed based on the test results, the documentation should clearly illustrate the provider's medical decision making and the medical necessity for the treatment.

One issue encountered often when conducting E/M coding audits is out-of-date problem lists. Such an oversight can lead to poor documentation, making problem lists an area of focus for physician practices looking to improve proper E/M code assignment.

Perfecting the Problem List in Physician Practices
In many physician practices, problem lists are not routinely reviewed and updated. It's common for providers to copy and paste prior problem lists into the documentation of new encounters, resulting in a list that is irrelevant to the patient's most recent visit.

When properly maintained, the use of a problem list in a patient's record facilitates continuity of care. An up-to-date, comprehensive problem list is invaluable to a treating provider.

Organizations such as The Joint Commission and the Accreditation Association for Ambulatory Health Care have issued standards for their constituents. Additionally, organizations such as ASTM International, Health Level Seven International, and the Healthcare Information Technology Standards Panel publish guidelines for the creation and maintenance of problem lists. AHIMA has compiled information in a document titled "Problem List Guidance in the EHR" regarding the standards and guidelines those organizations have published.

Practices struggling with correct E/M code selection are encouraged to evaluate problem list templates, processes, procedures, and compliance within their EHRs and with their staff.

Determining the Correct Level of Care Takes Time
Medical decision making, one of the key components of E/M coding, can be the most difficult to ascertain when assigning a code. To get the best results, it's recommended coders take a few minutes to examine the tests performed, determine why they were performed, and verify that the provider documented the rationale for ordering them.

As previously noted, the volume of documentation should not be the determining factor when selecting an E/M code. Since the level of E/M service is dependent on two or three key components, a higher level of service cannot be justified for the entire encounter if only one of the key components was delivered at the higher level.

On the flip side, a longtime patient may have a complex medical history with multiple problems, a situation that invites the potential for E/M undercoding. In this case, the provider may neglect to charge for the actual level of service delivered to an established patient.

In this scenario, the physician will likely review lab results alongside current symptoms before determining how to adjust one or more medications. These steps may be routine for this particular patient even though medical decision making in such cases is much more complicated. For patients with multiple chronic conditions, the higher level of service can—and should be—assigned.

With only five codes from which to choose, proper assignment of E/M codes appears to be a simple task. After all, EHRs are programmed to automatically select E/M codes based on documentation. However, there are many details to consider and guidelines to follow if proper reimbursement and quality scores are to be achieved. With value-based reimbursement on the rise, now is the time to ensure proper E/M coding at all levels of your health care organization.

— Nena Scott, MSEd, RHIA, CCS, CCS-P, CCDS, is director of coding quality and professional development at TrustHCS.