Consider these five tips to ensure accurate evaluation and management coding in your practice

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Office visit evaluation and management coding—also known as E/M coding—helps medical practices capture the time physicians spend with patients reviewing medical histories, performing examinations, and developing a care plan. Reporting the right E/M code means you’ll be paid accurately for the services you provide. If you underbill, you could leave money on the table. However, if you overbill, you could face costly denials and recoupments. Revenue integrity is the goal. Here are five tips to ensure E/M coding compliance in your medical practice.

1. Distinguish between new and established patients
This distinction determines what specific E/M codes you’ll report and how much you’ll be paid. For example, report E/M codes 99202-99205 for new patients and E/M codes 99211-99215 for established patients.

Updated evaluation and management code guidelines that took effect January 1, 2021 define new and established patients as follows:

• New patient: One who has not received any professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice within the past three years.

• Established patient: One who has received professional services from the physician/qualified healthcare professional or another physician/qualified healthcare professional of the exact same specialty and subspecialty who belongs to the same group practice within the past three years.

If you’re unsure whether a patient is new or established, talk to your medical coder or coding outsource vendor, and they can help you make the right medical coding choice. You can also use an evaluation and management coding calculator to guide you toward the correct E/M code.

2. Improve your clinical documentation
Consider these tips:

• Focus on medical decision-making.
  Be sure to document the number and complexity of problems you addressed and any assessments you performed.

• Don’t forget about social determinants of health (SDOH) that impact the patient’s care.
  SDOH count toward medical decision-making.

• Know what else affects medical decision-making.
  For example, reviewing prior external notes, ordering and/or reviewing unique labs or tests, prescription drug management, and more can play a role.

• Document a clinically relevant history and exam.
  This information is important from a clinical perspective and to justify medical necessity even though it no longer drives E/M code assignment.

• Document the total time for E/M services performed on the date of the encounter.
  This helps justify any time-based billing you perform.

3. Know when to report modifier -25
Modifier -25 denotes a significant, separately identifiable E/M service on the same day of a procedure or other service. Here are some tips that can help you ensure compliance with modifier -25 requirements:

• Don’t report modifier -25 if the procedure you perform resolves the presenting problem.

• When using modifier -25, best practice is to separate documentation for the E/M service from documentation for the separate procedure.

• Understand that some payers deny claims with modifier -25 as a matter of policy, or they automatically require additional documentation before paying the claim.

4. Know when to report modifier -24
Modifier -24 denotes an unrelated E/M service performed during a postoperative period. Before reporting modifier -24, ask this question: Is the service standard pre- and post-operative care for the procedure? If the answer is yes, that’s not enough for a separate E/M service.

5. Audit your E/M medical coding regularly
To do this, you can conduct the medical coding audit internally, or you could hire an external auditor to review a sample of your claims. In either scenario, the question to ask as you review evaluation and management coding examples is the same: Did I report the correct E/M code based on time or medical decision-making as documented in the medical record? Use your audit results to guide medical coding educational opportunities, redesign E/M templates, and implement new workflows.

Conclusion
Accurate E/M coding helps today’s medical practices survive and thrive in an increasingly competitive marketplace. It ensures your practice receives the revenue to which it is entitled—revenue that you can subsequently re-invest in your staff, your office, and your patients. You owe it to yourself to improve E/M coding accuracy. Learn how edgeMED can help and be sure to visit the Healthy Snacks Blog for more expert insights, best practices and industry trends.