Tips to Maximize Revenue from Evaluation & Management (E&M) Services

by | Last updated Dec 8, 2023 | Published on Dec 15, 2017 | Medical Billing

Evaluation Management Services
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Reporting evaluation and management (E&M) services is a challenge for primary care physicians. For medical billing companies, proper documentation of services and time by the provider is crucial to ensure proper reporting. According to a recent ICD10 Monitor report, physician practices and hospitals have varying interpretations of the E&M guidelines from the Centers for Medicare & Medicaid Services (CMS), which adds to the uncertainty. Nevertheless, physicians and medical billing and coding service providers can ensure accurate reporting by following certain guidelines. Here are some tips that can promote accurate E&M coding and increase practice reimbursement:

  • Correct documentation of medical necessity: Documentation is the key element when determining medical necessity. Insufficient documentation to support patient status determinations is a common reason for claim denial. Patient status impacts compliance, revenue integrity, metrics, and quality reporting. Points to note:
    • The correct level of E&M service should be reported, that is, the ICD10 Monitor report cautions that it is “not medically necessary or appropriate to bill a higher level of E&M service when a lower level of service is warranted”. For instance, if the visit does not necessitate detail to use 99214 – the second highest level of care for established office patients – a lower level should be reported.
  • Proper use of prolonged service codes: A Medical Economics report provides the following advice on the use of the prolonged service codes:
    • Prolonged service CPT codes 99354 and 99355 were revised in 2016 and can now be reported with 90837 (psychotherapy) as well as 99201-99215 (office visits), 99241-99245 (outpatient consultations), 99324-99337 (residential/assisted living) and 99341-99350 (home services).
    • Prolonged service code 99415 covers clinical staff service beyond the typical service time during an EM visit in the office or outpatient setting, direct patient contact with physician supervision; first hour (list separately in addition to code for outpatient EM service). Code 99416 should be used for reporting each additional 30 minutes.
    • Prolonged services codes cannot be reported for more than two patients at the same time.
    • Prolonged service codes cannot be used to report cumulative episodes of care by multiple, same-specialty providers within a group.
    • It’s not about the volume of documentation, but about documentation to support the level of service.
    • The note should support how the time was spent.

    Choosing the right E&M code depends on the appropriate level of history, the appropriate level of exam, and the medical decision-making. Billing higher on new patients and consultations is more complex, as all three levels of criteria must be met. Two of three criteria are required for established patients.

  • Customize EHR to capture the items required for the E&M guidelines for your practice: EHRs that prompt the physician about the inclusion of various organ systems or body areas when the physical exam is being done are more likely to capture the necessary data. The system can be computed to prompt diagnosis of obesity or morbid obesity. It is important to have good query templates for common conditions such as anemias, sepsis or septic shock, CHF, renal failure, pneumonias, and altered mental status on the diagnosis side. The documentation should be clear about present-on-admission conditions as well as hospital-acquired conditions.
  • Avoid electronic health record (EHR) documentation errors: Common EHR documentation errors include auto-population of fields, counting repeat work, cloned notes, and Level 4 and 5 visits. These errors can be avoided by avoiding auto-populating review of systems (ROS), past, family and medical history, and importantly, the physical exam. Unless care is taken to avoid these errors, the documentation could reflect an inaccurate picture of the patient’s condition, either at admission or as it alters over time. Providers should ensure that patient-specific data for each visit is recorded, while removing all other irrelevant data pulled in by the default template. For instance, AHIMA cautions that if the EHR automatically generates common negative findings within a review of systems for each body area or organ system, it can lead to a higher level of service delivered. To avoid this, the provider should document all pertinent positive results and delete the incorrect auto-generated entries.
  • Ensure continual assessment of E&M utilization: Providers need to ensure that their graph of Level 4s and 5s conforms to that reported in their state as well as at the national level and for their specialty. This requires evaluation of practice data on a monthly, quarterly, and yearly basis, and comparison with similar groups.
  • Both medical record and research documentation are necessary: A report points out that medical necessity decisions must be supported by critical concepts in the documentation, including severity of illness, presenting signs and symptoms, acuity, risk (the medical predictability of a short-term adverse event), intensity of hospital services, and any complications or comorbidities. During Medicare and auditors and commercial payer chart reviews, the auditors look for real-time documentation of what the physician is thinking and how concepts like acuity and risk are being integrated into the status decision. In addition to this, the treating physician’s admission decision should be supported by clinical judgment as well as by evidence-based medical research, says an expert.

Expert medical coding service providers work with physicians to ensure quality E&M documentation and report services using the appropriate codes. Partnering with an experienced medical billing and coding company is the best way for physicians to ensure data quality, improve patient care, and maximize revenue.

Rajeev Rajagopal

Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.

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