5 ways to stop undercoding your office visit E/M services in 2024
Office visit evaluation and management (E/M) codes can be tricky. You’ve got to choose the right level of E/M service, select the most specific ICD-10-CM diagnosis code, and then ensure detailed clinical documentation to support it all. If you fail to do any or all of these things, you’re most likely going to get a medical claim denial or post-payment recoupment. And while there are physicians who intentionally upcode their E/M services (i.e., report a higher-level E/M code than what was medically necessary), most people have good intentions—and may even ‘error on the side of caution’ by under-reporting their services.
However, undercoding Medicare claims and claims for other payers isn’t good either because it means could be missing out on reimbursement to which you’re probably entitled. How does one define undercoding? Undercoding occurs when you report a lower level of E/M service than what you provided—usually with the intention of avoiding payer audits. Keep in mind that undercoding in healthcare almost always backfires because payers often take note of physicians who bill below-average levels as well.
How to prevent undercoding in healthcare
Here are five ways to avoid undercoding your E/M services to promote revenue integrity and get paid what you deserve:
1. Choose the most beneficial E/M code selection criteria. As of January 1, 2021,you have two options for E/M coding: Based on time or medical decision making (MDM) (whichever ultimately yields the higher E/M level).
[Note that an important change took effect January 1, 2024. The CPT code descriptions for office visit E/M services no longer include time ranges. Instead, you must meet or exceed a minimum number of minutes on the date of the encounter. For example, E/M code 99204 previously included a time range of 45-59 minutes. Now, you must simply meet or exceed 45 minutes. E/M code 99205 previously included a time range of 60-74 minutes. Now, you must simply meet or exceed 60 minutes.
Here’s an example: Let’s say you spend a total of 11 minutes with an established patient on the day of their visit. In this case, you could report E/M code 99212. However, if your MDM satisfies requirements for E/M code 99213, you could select 99213. The key is making sure your documentation justifies any codes you assign. And of course, to avoid undercoding, don’t always default to the same criteria (i.e., always billing based on time or always billing based on MDM).
2. Know when to report a ‘new patient’ E/M code. New patient office visit E/M codes (i.e., E/M codes 99202-99205) pay more than ‘established patient’ codes (i.e., E/M codes 99212-99215). Here’s a flowchart to help you pick the right code range so you get paid correctly. Eventually, this E/M coding flowchart will become intuitive, so you know exactly how to prevent undercoding.
3. Count all the time you spend providing care for a patient on the day of the visit. This includes time before and after the visit (not just the face-to-face time during the visit itself). Counting this time correctly—and ensuring detailed documentation to support it—could easily help you increase your E/M level.
4. Add any relevant ICD-10-CM codes for social determinants of health (SDOH) onto the claim. SDOH can contribute to the complexity of patient issues, affecting both the time spent during an encounter as well as the level of MDM. This means it could help you justify a higher-level E/M code regardless of your selection criteria. The good news is that you may be able to create an electronic health record shortcut to document SDOH issues.
5. Add new HCPCS code G2211 for visit complexity, when appropriate. New for calendar year 2024 is HCPCS code G2211 that denotes the time physicians spend fostering a comprehensive, longitudinal, and continuous relationship with patients that involves team-based care. G2211 is for physicians who serve as the continuing focal point for all the patient’s healthcare services. Patients must have a chronic condition or single, high-risk disease. You can bill this code in addition to an office visit E/M code unless you are reporting the E/M code with modifier -25. This CMS resource provides two clinical scenarios that explain when and how to report G2211. If you do it correctly, you’ll get about an extra $16 per visit. Just make sure your documentation supports your extra cognitive effort and explains how the longitudinal doctor-patient relationship affects your diagnosis and treatment plan.
Promoting revenue integrity in your medical practice
While you don’t ever want to over-report or upcode office visit E/M services, you also don’t want to leave money on the table. That’s why it’s important to capture all relevant clinical details and then translate those details to the medical codes you report on the claim. Accurate coding is paramount. Learn how edgeMED can help and be sure to check the Healthy Snacks blog for more expert insights, best practices and industry trends.
