Under Coding Rates when billing for E&M Services

Why is Under Coding for E&M Services important?

For most medical practices, E&M services represent the bulk of their charges.

How can I reduce Under Coding for E&M Services?

If you understand and apply the medical documentation rules outlined by CMS in the 1997 E&M Documentation Guidelines, you will not under code. 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.

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