Overcome 2024 E/M Update Challenges with Expert Advice
Overcome 2024 E/M coding challenges with expert tips. Improve MDM understanding, documentation clarity, and compliance for accurate, higher reimbursement.
PCP Medical Billing & Coding Alert
Get tips on how and when to query
When the inpatient evaluation and management (E/M) guidelines aligned, some coders and physicians felt uncertain.
To address these challenges, industry experts conducted audits and case studies to identify areas of confusion. These findings provided valuable insight into the difficulties coders face with E/M changes.
Challenge 1: Breaking Old Habits
Breaking habits can be a physical and psychological challenge, particularly in the fast-moving healthcare environment. Coders are trained to keep pace with changes, which is already difficult enough. For physicians, it can be even harder. For years, they were focused on documenting the volume of what they examined, but now the emphasis has shifted to the quality of the documentation. If a physician is used to noting only the areas of the body they examined without providing insight into their thought processes, test rationale, potential diagnoses, and the associated risks of the condition and its management, the documentation is unlikely to support the level of reimbursement expected.
Challenge 2: Gaps in Documentation
Experts have observed that, although accuracy rates are improving, many practices continue to need help with under-coding or over-coding. Some physicians under-code due to confusion or fear of the consequences of over-coding, while others over-code, either because they’re following outdated guidelines or due to incomplete documentation. To assign the most appropriate E/M level, providers’ notes must include more detailed information.
- Severity of Risk: Assessing the severity of risk when documentation lacks clarity can be difficult. For example, if a high-risk patient decides to stop treatment, they may still be considered high-risk.
According to Cox, it’s essential to document what other treatment options were discussed and why they were considered.
- Status of Conditions: The documentation should clearly reflect the status of relevant conditions. For instance, if a patient with diabetes has no complaints, does that mean their condition is stable, or do they simply not report any issues? What if lab results suggest instability? Cox emphasizes that the actual status must be documented.
- Data Elements: Simply noting that a patient continues their medication doesn’t automatically count as moderate risk. For it to qualify, there must be a change in the medication regimen, or the physician must specifically address the medications' impact on the risk level, Cox explains.
- Differential Diagnoses: Physicians often leave out their clinical reasoning and thought processes, which are crucial for assessing medical decision-making complexity. A well-documented differential diagnosis not only aids future healthcare professionals but also demonstrates the complexity of the case, supporting a higher level of E/M coding.
Challenge 3: Understanding the Relationship to MDM
The lack of detailed documentation often arises from a broader lack of understanding. Providers may need to recognize the importance of documenting the nature of the problem or the associated risk, and coders struggle to interpret vague notes.
- Nature of the Problem(s) Addressed: It’s essential to document why the patient is seeking care and the number and complexity of the problems being addressed. This is key to Medical Decision Making (MDM) because it helps guide the physician in determining which tests to order, further examinations to conduct, and potential diagnoses to consider.
- Risk: Risk is specific to each patient and their condition on a given day. For example, a healthy patient with a sinus infection is at low risk, while an elderly or HIV-positive patient with multiple comorbidities may face a higher risk from the same condition. Social determinants of health (SDoH) also play a significant role. For instance, a homeless patient may be at moderate or high risk due to poor self-care. Cox explains, “Diagnosis or treatment significantly limited by social determinants of health” is categorized as moderate risk in the MDM table.
- Data: The data element in MDM can be tricky, even for experienced coders. It is often ambiguous, but there are key areas that physicians routinely fail to document:
- Who is Present: For example, a baby can’t communicate its symptoms, so it’s important to document who is in the room. An independent historian, such as a parent or caregiver, counts toward the data element.
- Review vs. Interpretation: It’s important to distinguish between simply reviewing data and interpreting it independently. If the physician looks at an X-ray or a report on a meniscus tear but provides an independent interpretation, that counts toward the data element. However, simply reading the report doesn’t qualify unless they explain the findings in detail.
Challenge 4: Time Documentation
Time documentation can be challenging because many providers fail to document specific times, making it difficult to determine whether Time or MDM should be used—whichever is higher should guide the coding for appropriate reimbursement. Some electronic systems automatically adjust the level based on the noted time, leading to potential errors in coding.
Additionally, when separately reportable procedures, such as X-rays, are involved, the independent interpretation of that procedure cannot be counted towards the total time for the E/M encounter, as it’s already compensated as part of the procedure itself. However, this is often unclear in the notes. Vague entries like “spent more than 20 minutes with the patient” are inadequate because E/M codes refer to the total time spent on the day of the encounter, not just with the patient. Simply marking 30 minutes for every patient is also problematic, as the time required can vary.
How to Solve These Challenges?
Recognizing the common problematic areas is useful, but improving processes requires action:
- Reassess the Compliance Program: A strong compliance plan is essential, but it’s ineffective without support from leadership. Effective teamwork across all levels strengthens compliance audits. When improvements aren't observed, regular education, audits, reaudits, and revisions to training programs are necessary. Proactive organizational action is key.
- Perfect Physician Queries: Coders and physicians often struggle to communicate effectively due to different professional shorthand. Understanding when and how to query is critical:
- Know When to Query:
- Is there conflicting information?
- Are there unsupported statements?
- Does documentation need to be legible or complete regarding the reason for the visit, patient acuity, risk, or treatment?
- Know How to Query:
- Write clear and concise questions.
- Include relevant clinical indicators from the record.
- Present factual information to support the need for clarification (avoid leading the physician).
- Do not mention reimbursement impact.
- Follow practice guidelines.
- Be respectful.
- Use yes/no questions when possible and appropriate.
- Know When to Query:
BillingFreedom A Trusted Partner for Accurate and Compliant Medical Billing
BillingFreedom is the ideal primary care medical billing partner because of its deep understanding of complex coding systems and modifiers and dedication to accurate documentation. With expertise in the latest E/M guidelines, we ensure that every element of Medical Decision-Making (MDM)—from the nature of the problem to risk and data elements—is meticulously captured. This attention to detail prevents under- or over-coding, optimizing reimbursement and compliance.
Moreover, we excel in overcoming common challenges, such as breaking old habits, improving time documentation, and effectively managing physician queries. Our team’s proactive approach to reassessing compliance programs, conducting regular audits, and maintaining open communication with physicians ensures that your practice stays up-to-date and fully compliant.
By focusing on accurate, comprehensive documentation, we help practices avoid costly errors, streamline revenue cycles, and improve overall billing efficiency, making it the best partner for your billing needs.
For more details about our exceptional medical billing services, please don't hesitate to email us at info@billingfreedom.com or call us at +1 (855) 415-3472.
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