Uncovering 5 Common Gray Areas of E/M Coding

There can be a lot of ambiguity in E/M coding. Let’s get to the bottom of common problem areas in exam, history, using time to bill, and medical decision-making (MDM), to address misconceptions and answer some important questions related to some of these abstruse topics.

1. Documenting History

The best way to document history is by the provider. There are no guidelines specifying that nurses or any other staff besides the provider can take the chief complaint. If it is recorded by ancillary staff, the physician must review and sign the form with a notation specifying that it was originally recorded by someone else. Most auditors won’t accept CCs recorded by someone other than the physician.

2. Defining Interval History

Interval history is defined as a type of health history that documents a client’s condition in between visits. CMS E/M guidelines indicate that, “For certain categories of E/M services that include only an interval history, it is not necessary to record information about the PFSH.” This means you would subtract any PFSH normally required for a history level. There is no difference between a problem-focused history and a problem-focused interval history for auditing purposes. 

3. Performing the Exam

Everything aside from taking vital signs must be performed by the provider, according to the 1997 guidelines.

4. Single Organ Exams

According to the guidelines of 1995, a Comprehensive Exam is defined as, “A general multi-system examination or complete examination of a single organ system.” Establish how many specific findings must be documented for a complete exam of a single organ system by checking your local Medicare carrier.

5. Data Gathering Activity Documentation Should Be Thorough

Diagnostic and lab tests should thoroughly document the information obtained. Additional family history or caregiver history along with other sources and relevant information should be properly documented. A lack of relevant information must also be documented for crediting purposes.

For more information on the “gray areas” of coding, download our more thorough ebrief, "Common E/M Coding Conundrums", by clicking the button below:

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