Strategies to Prevent E/M Mistakes and Denials

by | Mar 25, 2020 | Blog, Insurance Updates | 0 comments

A large volume of the claims processed by medical billing companies are those for evaluation and management (E&M) services. The key to maximizing payment and avoiding risk of audits is proper documentation and coding of E/M patient visits.

The main reasons for the denial of E/M claims are assigning the wrong codes and reporting codes that do not support the services provided. Here are top strategies to prevent E/M mistakes and denials:

Choose the code that best represents E/M services rendered: There are different levels of E/M codes, which are governed by the complexity of the visit and documentation requirements, and certain other factors. According to CMS, the main variables that need to be taken into account when selecting E/M codes are:

  • Patient type (new or established) – New patients are those who have not received any professional service from the healthcare provider within the last three years; established patients are those who have received professional service from the healthcare provider within the previous three years.
  • Setting/place of service – The physician-patient encounter could take place in an office or outpatient setting, a hospital inpatient, an emergency department, or a nursing facility
  • The level of service provided based on the extent of the history, the extent of the examination, and the complexity of the medical decision making (i.e., the number and type of the key components performed). Typically, the higher the complexity of the encounter, the higher the level of the code reported. Unless coding based on ‘time’, these three key components are enough to meet E/M documentation requirements.

Starting January 2020, evaluation and management (E/M) has new codes for e-visits that Medicare will reimburse.

Provide clear documentation for Level 4 Office Visits: When time is the main element in the patient’s visit, the appropriate time-based service code needs to be captured. However, choosing a , Level 4 E/M code based on time, proper documentation that clearly describes what was done and why is crucial, according to a 2018 Medical Economics article. The reason is that Level 4 E/M codes come under payer scrutiny as they are associated with higher payments. The report notes that if the physicians choose a Level 4 E/M code based on time, their documentation must clearly describe what was done and why. In the absence of proper documentation, the physician could come under the microscope if the payer suspects upcoding. The article notes that focusing on diagnosis codes can help justify the basis for E/M level selection based on time.

Another point to note is that time spent on extent of the counseling and coordination of care should also be documented. These services are above and beyond the E/M code and documentation must really reflect this fact.

Ensure services rendered are “reasonable and necessary”: According to CMS, when assigning an E/M level, medical necessity means “the service is furnished in accordance with accepted standards of medical practice for the diagnosis or treatment of the patient’s condition.” Medical necessity is determined by the severity of the patient’s presenting problem. To prevent claim denial, it should be ensured that the service provided was reasonable and medically necessary.

Follow documentation rules: If it wasn’t documented, then it wasn’t done. Physicians should ensure clear and legible documentation in the medical record. New documentation guidelines for office- and outpatient-based E/M services came into effect on January 1, 2019. According to these rules, the provider can reference previous information and document an update from the last visit. However, physicians should know the documentation guidelines followed by their non-Medicare payers as these may differ from CMS guidance.

Stay informed about updates: The AMA recently released CPT errata and technical corrections ( and knowing these changes is necessary to ensure correct coding. The Evaluation and Management section, under the Non-Face-to-Face Services heading, the Remote Physiologic Monitoring and Treatment Management Services introductory guidelines has been revised to specify that codes 99457, 99458 should be reported for the first completed 20 minutes and each additional completed 20 minutes, respectively, of clinical staff/physician/other qualified healthcare professional time in a calendar month. Other changes include:

  • Deletion of the second instructional parenthetical note following 99458 that states: “Report only 99457 if you have not completed 20 minutes of additional treatment regardless of time spent.” Do not report 99457 for services of less than 20 minutes.
  • Revision of the third instructional parenthetical note following 99458 to read: “Do not report 99458 for services of less than an additional increment of 20 minutes.”

These updates became effective Jan 1, 2020.

The best way to reduce claims denials is to outsource medical billing and coding to an experienced service provider. With proper clinical documentation of E/M visits, an experienced medical billing company can help practices reduce denials and increase revenue.

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