E/M Coding And Auditing: How To Avoid Wrongful Code Selection

“Use your words,” my mom used to say. And, as with most things, she was right. Words are important. But they’re especially important in the medical field where the right words can mean the difference between accurate evaluation and management (E/M) coding and the wrong words can result in someone being accused of submitting false claims.

Ouch.

After years of auditing experience and endless auditing conversations, auditors understand the potential for ambiguous language in medical records and they learn how to decipher meaning from poorly documented intent. Auditors, aka healthcare translators, understand how a reader might interpret words (traps) and remedies for such ambiguity (tricks). There’s no doubt in my mind that many of you are nodding your heads in agreement right now, thinking, “Oh, yes, me too.”

Our short eBrief, Decoding E/M Services: Auditing Traps And Word Tricks, covers the best:

• Methods to document e/m visits
• Strategies for reducing coding ambiguity
• Ways to avoid potential allegations of wrongful code selection

An Example Of Word Traps And Word Tricks:

Non-Contributory

The TRAP: Most payer auditors disallow a history element or review of systems that is described as “non-contributory.” The rationale is that there is not sufficient information provided to adequately understand which questions the patient was asked regarding his/her history and/or review of systems. Physicians commonly tell us that they “meant” that the patient’s response was negative and, therefore, did not direct the evaluation in a specific direction.

The TRICK: If what is meant is that the patient responded in the negative, document “family history is negative for whatever you asked about,” or that, “the review of systems is negatively related to state the systems asked about.”

REMEMBER, WORDS DON’T DRIVE THE CODE
Perhaps the biggest trap of all is thinking that words drive the code. While it’s important to completely record the work done, doing it for the “sake of a code,” may not stand up to audit scrutiny.

What is your experience with word traps and word tricks? Have any you want to add to our list? What advice would you give when dealing with ambiguous language? Go ahead and put it in the comments section below.

For more examples of word traps and word tricks, download our eBrief, Decoding E/M Services: Auditing Traps And Word Tricks.