Why is E&M Coding Accuracy important?
For most medical practices, E&M services represent the bulk of their charges. Accurate coding ensures that you are paid for the medical services you actually provide and reduces your RAC audit risk. The data was extracted from 429 clinic notes from a family medicine residency program. Coding accuracy was determined by comparing the billed CPT code to the CPT code supported by an audit of the clinic note.
How can I improve E&M Coding Accuracy?
If you understand and apply the medical documentation rules outlined by CMS in the 1997 E&M Documentation Guidelines, you will code properly and accurately. You can get one of our free E&M Coding Cheat sheets to help remind you of what needs to be documented to qualify for a specific level of service.
The study by Skelly and Bergus indicates that substantial improvements in E&M coding accuracy, practice revenue, and regulatory compliance could be made with practice improvement efforts directed at E&M coding accuracy.
What are E&M Services?
E&M services are easily recognizable medical services such as a visit to urgent care, hospital admission, or daily rounds on people admitted to a hospital. These services have multiple levels which correspond to different levels of medical complexity, such as a ‘new outpatient visit – level 4’. Selecting the correct level of service is critical to being paid appropriately for the patient encounter. Medicare released guidelines on how to select the proper service level in 1995 and 1997. These E&M Documentation Guidelines serve as the rulebook for E&M coding for physicians in the USA.
Not all medical services are covered under the E&M Documentation Guidelines. Surgeries, lab tests, preventative medicine, counseling, and imaging studies have separate documentation rules.
References on E&M Coding
- HGSA Documentation worksheet
- Skelly KS, Bergus GR. Does structured audit and feedback improve the accuracy of residents’ CPT E&M coding of clinic visits? Fam Med. 2010 Oct;42(9):648-52.
- 1997 Documentation Guidelines for Evaluation and Management Services
- 1995 Documentation Guidelines for Evaluation and Management Services