3 Common E/M Auditing Challenges

Getting the most out of an E/M audit can be as simple as paying extra attention to common coding and documentation errors, common exam mistakes, and Medical Decision Making (MDM) mistakes. Armed with the right knowledge, you’ll be able to create a solid action plan for improving documentation and coding and conduct a successful audit.

1. Coding & Documentation Errors:

Common coding and documentation errors include an undocumented chief complaint on hospital subsequent visits and office notes with insufficient documentation of follow up services. Other common errors occur when the history of present illness or HPI is not completed by the provider, or when the status for chronic condition is not actually backed up with documentation.

2. Exam Mistakes:

Common exam mistakes include lack of documentation, such as forgetting to check a box in a template, pulling the exam portion of an EHR note, or mixing body area and organ systems when using the 1995 Documentation Guidelines for E/M Services. When using check boxes in templates, the provider does not elaborate on “abnormal findings.”

3. Medical Decision Making (MDM) Mistakes:

Common medical decision making (MDM) mistakes include a lack of, or incomplete, documentation for a formal assessment and plan. A MOM based only on severity, risk or the number of presenting problems, incorrectly documented time-based visits, medication orders not linked to assessments, and a diagnosis that lacks specificity.

Remember, your role as an auditor is to advocate, educate, and train coders and providers. If you know the common challenges, you can easily help providers to capture all of the work they have performed, so they can get paid properly.

For the complete guide to E/M Auditing Challenges, and how to conduct an effective chart audit, download our free eBrief by clicking the button below: