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Most electronic health record (EHR) systems are designed to help physicians and medical coding service providers choose the appropriate evaluation and management (E/M) CPT codes for patient encounters. Using these tools correctly is necessary to ensure accurate coding based on medical necessity to support higher levels of E/M coding and thereby, higher reimbursement. However, it has been found that electronic health record (EHR) software design flaws, poor implementation, and lack of user knowledge on how the E/M coding systems function could lead to inaccurate coding and denials.EHR

According to a recent Medical Economics report, use of EHRs by physicians is causing errors in reporting high-level E/M codes, which are as follows:

99204 (Level 4 office visit, new patient)
99205 (Level 5 office visit, new patient)
99214 (Level 4 office visit, established patient)
99215 (Level 5 office visit, established patient)

EHR based computer-assisted E/M Coding (CAEMC) has several limitations:

EHRs have a tendency to add irrelevant information into the clinical record through templates or default information. EHR templates may prompt physicians to choose higher levels of E/M services when the medical necessity may be absent. Instead of using SOAP (subjective, objective, assessment, and plan) documentation methods, the physician may end up answering questions prompted by the EHR template which may have no relevance to the patient’s presenting problem.

Another problem causing errors in coding E/M services occurs when physicians create their own templates and assume that specific diagnoses automatically support a certain level of E/M service. For instance, not every patient presenting with abdominal pain can be reported using CPT code 99204 – Level 4 New Patient Office Visit. The physician should document elements that support medical necessity. Errors in reporting E/M service occur if the EHR prompts the physician to document a level of service instead of medical necessity.

According to an AAPC report, a review of EHRs that had a reported combined client base of more than 80,000 physicians found that EHRs generated higher-level E/M codes than what were supported by documentation by including irrelevant information (by default) or sections of the record that were improperly “cloned” (i.e., copied from previous records and pasted into the current document). There were no alerts that a section of the record was copied and might contain erroneous information. This problem can be avoided if the physician takes time to check whether information is relevant to the current visit and pay attention to the suggested code.

Other issues include

  • Difficulty in using complex EHR tools for selecting the correct E/M code during patient care
  • Lack of knowledge of best coding practices when using their specific EHR system
  • Unfamiliarity with E/M coding guidelines

Here are the best practices for using EHRs for reporting of E/M services:

  • Pay attention to E/M levels for the same patient over time. Payers generally look for a slow progression downward in the levels. If the physician reports an established patient who presents with an acute exacerbation of COPD using CPT code 99215, the payer would not expect the physician to continue to report this code for each subsequent visit over the next few months.
  • Report level 5 codes only for patients at considerable risk for loss of life or bodily function. Medical Economics cites an expert as saying that CPT codes 99215 and 99205 should be used for “patients with symptoms of an impending heart attack or a severe exacerbation that requires additional workup or an immediate referral to a specialist or the hospital”.
  • Report diagnoses correctly: Physicians should report all of the diagnoses they manage and treat. This is necessary to prove that the services provided were medically necessary.
  • Avoid billing too many level four and five E/M visits: Higher-level E/M codes are justified when patients actually require more complex medical decision-making or time. However, billing too many level four and five E/M visits can attract audits. Doing so would also hurt other providers in your locality who may be billing correctly. The solution is to review the volumes of E/M levels reported and compare it to specialty-specific Medicare utilization data.
  • EHRPay attention to payer communications: Payers may point out irregularities in the data and it’s important to heed these communications and make sure that their coding and billing practices are correct.
  • Validate EHR-prompted codes: Flawed templates can lead to up-coding and result in E/M levels that are higher than average. On the other hand, down-coding errors can lead to lost revenue. Upcoding and downcoding can be avoided by validating EHR-prompted codes before reporting E/M services.
  • Ensure proper documentation: One common error is lack of documentation to support the level of E/M services billed. Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. 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,” according to the Centers for Medicare & Medicaid Services (CMS) Medicare Program Integrity. Documentation should support the level of service reported and include the following key components: Extent of History, Extent of Examination, and Complexity of Medical Decision Making (MDM). Higher-level E/M codes documentation should justify the higher-level code.

Partnering with an experienced medical coding company can help providers avoid denials, rejections, penalties, and charges of fraud. Skilled coders have a proper understanding of HER software design and on how the E/M coding systems function. They can help physicians adhere to best coding practices when report high level E/M codes to maximize revenue.