|
|
| |
By Peter R. Jensen, MD, CPC
Rational Physician Coding is a purpose-driven strategy for E/M coding which eliminates undercoding, ensures 100% compliance and streamlines the documentation process. Rational Physician Coding lets the clinical circumstances of the patient--rather than the subjective impulses of the physician--determine the correct level of care.
Most physicians have a hard time being compliant with the E/M guidelines because they don’t have a concrete plan to apply them in daily practice. In the current climate of increasing regulatory scrutiny, it is reckless and naïve to cobble together your documentation, circle an E/M code and simply hope for the best. Now, more than ever, forces are gathering to squash physicians who demonstrate a casual attitude toward E/M compliance.
The Traditional Approach to E/M Coding Doesn’t Work
Ever since medical school, we have been taught to document our encounters in a linear manner. First you take a history, then you perform a physical exam and then you go through a process of medical decision-making to come up with and an assessment and plan. When we were introduced to the concept of selecting an E/M code for the encounter, most physicians simply performed the documentation and then looked back at what they did to come with an E/M code. |
 |
The problem with this approach to documentation is that it doesn’t work. This may be a good way to gather clinical data, but it is a terrible way to document that information if you have to use the rigid format governed by the E/M guidelines. In this traditional approach, the history and physical exam are documented more or less at random. When you consider the arbitrary nature of the E/M guidelines, relying on sheer entropy to maintain documentation compliance is not a good idea.
|
Rational Physician Coding: Moving Forward by Working Backwards
I became so frustrated with the process of E/M coding that I went back to school and eventually became a certified professional coder. I taught myself to be an expert at interpreting the E/M guidelines and finally gained some insight into the process. One of the most alarming things I learned was that the E/M guidelines were not designed for doctors, but for auditors. These rules were never meant to "guide" physicians. They were designed to act as a roadmap for auditors. After a lot of trial and error, I came up with a solution that I call Rational Physician Coding. Rational Physician Coding shifts the paradigm of physician E/M coding and documentation to favor doctors rather than auditors. Instead of randomly documenting the history, then the physical exam and finally the medical decision-making, Rational Physician coding directs the physician to try working backwards. Consider the medical decision-making first. Once the level of MDM has been determined, you can select the appropriate “target” E/M code which is congruent with the cognitive labor provided during the encounter. With this target code clearly in mind, the documentation can be performed in a purpose-driven and prospective manner. This leads to 100% E/M compliance (because you know your target code and documentation requirements ahead of time) and also eliminates undercoding (because the level of care selected always matches the medical decision-making).
Four Steps to Rational Physician Coding
- Calculate the Medical Decision-Making
- Identify the "target code"
- Determine the documentation required
- Make sure it is reasonable and medically necessary to do what the documentation asks
Forewarned is Forearmed
The cornerstone of Rational Physician Coding is the concept that accurate E/M coding and documentation must be performed in a logical and step-wise manner, with clear goals in mind for the physician. This means that a target E/M code for each visit must be determined prior to starting the documentation. The only ethical way to pre-select this target code is to calculate the medical decision-making first. |
 |
Let the Medical Decision-Making Lead the Way
The medical decision-making can be easily quantified by using an objective point system (see chapter on medical decision-making). After the level of MDM has been determined, the cognitive labor may be used as an ethical “compass” to point the physician directly toward the appropriate target E/M code. With this target code in mind, the physician can refer to any standard E/M reference card and determine the documentation required for the present encounter. The documentation is then performed in a premeditated manner to ensure that all the proper elements of history and/or physical exam are included. This guarantees perfect compliance every time. |
 |
Rational Physician Example for an EstaCodingblished Office Patient
Rational Physician Coding Uses the E/M Guidelines to the Maximum Advantage of Physicians
The great thing about using Rational Physician Coding is that it allows physicians to use the E/M guidelines in an ethical and rational manner. You can thinkof it as a self-auditing process which optimizes reimbursement and ensures perfect documentation. This is not about “gaming” the system, but simply about finding a way to apply the rules in a systematic manner to ensure compliance and avoid undercoding.
In order to apply the principles of Rational Physician Coding, you need to be conversant with the E/M guidelines and the various rules of documentation. The remainder of this tutorial is designed to help physicians and coders understand these rules. Once you have a firm grasp of the fundamentals of E/M documentation, you can apply the principles of Rational Physician Coding in daily practice and say goodbye to E/M coding anxiety and undercoding.
|
Introduction and Definitions
The purpose of this tutorial (and of this entire website) is to provide physicians with the tools they need to educate themselves about E/M coding and documentation. The fundamental principle of E/M University is that knowledge is power when it comes to E/M coding and documentation. Too many physicians are chronically undercoding for their services because they don’t understand the rules. A working knowledge of the E/M coding is the best way to ensure optimal compliance and avoid inadvertent undercoding. Physicians who are facile with the idiosyncratic process of E/M documentation can command a higher rate of return on their cognitive labor than their less E/M-savvy counterparts. In other words if you know how to accurately bill for your services, there is a better chance you will get paid for what you really do.
E/M stands for “evaluation and management”. E/M coding is the process by which physician-patient encounters are translated into five digit CPT codes to facilitate billing. CPT stands for “current procedural terminology.” These are the numeric codes which are submitted to insurers for payment. Every billable procedure has its own individual CPT code.
The CPT codes which describe physician-patient encounters are often referred to as “E/M codes” There are different E/M codes for different types of encounters such as office visits or hospital visits. Within each type of encounter, there are different levels of care. For example, the 99214 code may be used to charge for an office visit with an established patient. There are five levels of care for this type of encounter. The 99214 code is often called a “level 4” office visit because the code ends in a “4” and also because it is the fourth “level of care” for that type of visit (with the 99215 being the fifth and highest level of care). Each patient care encounter may be viewed as a unique procedure which requires specific documentation.
The Key Components of E/M Documentation
The documentation for E/M services is based on three “key” components:
- History
- Physical Exam
- Medical Decision-Making
E/M University Coding Tip: The key components are used to satisfy the documentation requirements for E/M coding UNLESS the physician is coding based on TIME. If time is the controlling factor, there are no specific documentation requirements for the three key components.
The E/M key components can be thought of as the building blocks of documentation for all patient encounters. Some types of encounters require complete documentation of all three key components, while others require only two out of three. The E/M Guidelines
The documentation requirements for each individual E/M code are dictated by a set of rules called the E/M guidelines. The E/M guidelines were developed by the Center for Medicare and Medicaid Services (CMS) in conjunction with the American Medical Association. Two versions have been released—the first in 1995 and the last in 1997.
The Complete 1995 and 1997 E/M guidelines may be downloaded by clicking here.
For a more detailed discussion about which version may be best for you, click here.
The E/M guidelines define the requirements for individual E/M codes based on the extent of the documentation of the three key components. In general, higher paying E/M codes (like consultations or initial office visits) require more extensive documentation than lower paying codes (such as office visits with established patients or hospital progress notes).
E/M University Coding Tip: The physician MUST choose to use EITHER the 1995 OR the 1997 E/M guidelines. It is NOT acceptable to mix and match elements from both sets of rules within the body of the same note.
E/M University Coding Tip: The 1995 and 1997 E/M guidelines are practically identical when it comes to the key components of history and Medical Decision-Making. The main difference between the two versions lies in the documentation required for the physical exam (see 1995 Vs. 1997 E/M guidelines).
E/M University Coding Tip: Due to increased flexibility for recording the HPI, most physicians should use the 1997 E/M guidelines for encounters where the patient has no spontaneous somatic complaints.
The E/M guidelines define the requirements for individual E/M codes based on the extent of the documentation of the three key components. In general, higher paying E/M codes (like consultations or initial office visits) require more extensive documentation than lower paying codes (such as office visits with established patients or hospital progress notes). In order to understand E/M coding, it is first necessary to understand each of the individual key components which are explained in our tutorial.
|
|
|
|
