It is essential that we code and document every patient encounter accurately so as to maximize revenues and avoid potential audits and recoupments later. It is imperative that we document all procedures that are performed. Any procedure that is not documented would be considered as not performed by the payors.
While coding the E&M codes, we need to be careful in choosing the right level of code. We should choose the right E&M code level based on the Complexity of MDM (Medical decision making that is involved in the evaluation of the patient), once we arrive at the level of code based on the level of medical decision making : MDM, we need to ensure that we have sufficiently documented the progress note to support the required level of History and Physical Exam.
For e.g if you see a Patient for f/u in hospital for whom the MDM is moderate then as per MDM which points to level 2, we should code only level 2 CPT 99232 and we need to document a EPF (Expanded problem focused) History and an EPF Exam, this would ensure that we comply with regard to Coding and Documentation
guidelines
Instead for the same patient if we have not adequately documented the progress note, let us assume that we have documented only a PF History and PF Exam and have billed CPT 99232, then we may get paid for CPT 99232, but in case of an audit later, CMS / other payors could recoup the payment for inadequate documentation
Another scenario for the same patient would be wherein, we have documented more than what is needed, let us assume that we have documented a Detailed History and a Detailed Exam and have billed CPT 99233 instead of CPT 99232 as per MDM, then again CMS / other payors may recoup the payment for lack of medical necessity / upcoding.
Hope the above examples give you some idea as to Coding the levels and the documentation required. Please refer the below link for CMS manuals on Coding and Documentation. http://www.cms.gov/Outreach-and-Education/Outreach-and-Education.html
While coding the E&M codes, we need to be careful in choosing the right level of code. We should choose the right E&M code level based on the Complexity of MDM (Medical decision making that is involved in the evaluation of the patient), once we arrive at the level of code based on the level of medical decision making : MDM, we need to ensure that we have sufficiently documented the progress note to support the required level of History and Physical Exam.
For e.g if you see a Patient for f/u in hospital for whom the MDM is moderate then as per MDM which points to level 2, we should code only level 2 CPT 99232 and we need to document a EPF (Expanded problem focused) History and an EPF Exam, this would ensure that we comply with regard to Coding and Documentation
guidelines
Instead for the same patient if we have not adequately documented the progress note, let us assume that we have documented only a PF History and PF Exam and have billed CPT 99232, then we may get paid for CPT 99232, but in case of an audit later, CMS / other payors could recoup the payment for inadequate documentation
Another scenario for the same patient would be wherein, we have documented more than what is needed, let us assume that we have documented a Detailed History and a Detailed Exam and have billed CPT 99233 instead of CPT 99232 as per MDM, then again CMS / other payors may recoup the payment for lack of medical necessity / upcoding.
Hope the above examples give you some idea as to Coding the levels and the documentation required. Please refer the below link for CMS manuals on Coding and Documentation. http://www.cms.gov/Outreach-and-Education/Outreach-and-Education.html
