Addressing Challenges in Office/Outpatient E/M Coding: Key Insights

Table of Contents

Introduction:

The major revisions to the coding guidelines for office/other outpatient evaluation and management (E/M) visits (CPT codes 99202-99205 and 99211-99215) were implemented nearly four years ago. While these updates aimed to streamline the coding process, practices continue to encounter challenges in documentation and reporting. Such confusion can lead to improper coding and potential financial repercussions.

1. Review the Basics with Providers:

Focus on Medical Necessity: Begin by discussing medical necessity with providers and its alignment with standard medical care practices. Emphasize the importance of focusing on what constitutes good medical care, independent of coding and revenue considerations.
Standard of Care: Remind providers that their work follows established standards of care. If they base documentation on what they were trained to evaluate and test, it aligns with medical necessity and reduces coding risks.
CMS Documentation Definition: Reinforce CMS’ definition of documentation as a communication tool that outlines the “who, what, when, why, and how” of patient care. Proper documentation supports medical necessity and minimizes the risk of improper payments.
Future-Proof Documentation: Advise providers to document thoroughly so they can recall the details of a case even years later, ensuring that their documentation remains relevant for future reference.
Signature Requirement: Stress the importance of signing records, orders, and notes to avoid common documentation errors.

2. Four Ways to Avoid Attracting a Payer Audit:

Below some common practices that could invite unnecessary payer scrutiny:

Consistently Billing the Highest Level of E/M Services: Avoid routinely billing the highest level of services, which can trigger an audit.
Billing “Incident-To” Services: Refrain from billing everything as an “incident-to” service, as this can raise flags.
Misuse of National Provider Identifier (NPI): Do not report one doctor’s services under another provider’s name and NPI.
Modifier -25 Misapplication: Avoid applying modifier -25 to every E/M visit that occurs on the same day as another service, unless it is truly warranted.

By avoiding these behaviors, practices can reduce the likelihood of drawing attention from auditors.

3. Four Lingering Challenges Practices Face:

Persistent challenges in implementing office and outpatient E/M coding guidelines:

Role of History and Examination: Although history and examination are no longer the primary metrics for coding, they remain essential in supporting medical necessity. Even when coding based on time, documenting the reasons for the time spent on a visit provides context for medical necessity.
Cloning of Notes: Despite efforts to minimize cloning, practices still struggle with copied notes. Providers must monitor and avoid excessive cloning, as it can undermine the documentation’s support for medical necessity. Repeatedly copied data may not justify the higher levels of care that the notes initially appear to support.
CPT Manual Ambiguity: Although the American Medical Association (AMA) has made efforts to clarify the new guidelines, some ambiguity persists. Practices should stay updated with refinements from the CPT Editorial Panel and ensure compliance with both CMS and private payer interpretations of the guidelines.
Reliance on Old Guidelines: Many practices continue to rely on outdated guidelines. It is crucial for practices to unlearn old practices and adapt to the new guidelines. Mixing old and new guidelines during audits can lead to errors, and providers must be retrained to follow the current standards.

Conclusion:

Addressing these challenges requires ongoing education and clear communication with providers about medical necessity, proper documentation, and adherence to updated coding guidelines. By focusing on best practices and understanding the nuances of the revised guidelines, practices can avoid costly mistakes and ensure compliance with payer requirements.