Evaluation & Management Part 1: the History Component

MedPro Services strives to maintain current knowledge of the ever-changing medical billing and coding industry.  In one of our many continuing education efforts, a group from the MedPro Services’ team recently attended the Karen Zupko & Associates conference on General Surgery coding in Chicago, IL.  With the recent changes in the healthcare industry, medical billers/coders and providers alike must be especially vigilant in maintaining appropriate and accurate practices.  Insurance companies are cracking down on coding and billing errors and ensuring that provider reimbursement reflects services rendered.  With insurance auditing on the rise, providers must make sure that documentation and coding meets the Centers for Medicare and Medicaid Services (CMS) guidelines.  Over the next few weeks, I will be writing a series of posts highlighting some of the most integral aspects of what we learned at the conference and what we feel providers should know to keep their practices operating as efficiently and successfully as possible.

Today’s post focuses on something almost everyone in the medical billing industry is highly aware of, are continuously learning about, and is one of the most commonly miscoded and over-billed services: the evaluation and management (E/M).  This was a hot topic at the conference and something that all medical billing companies should be acutely aware of and knowledgeable on.  From personal experience, I can tell you that E/M codes are notoriously difficult to code simply because the CMS language is not as clear as it is for other areas of coding.  The most important thing to consider when coding E/M services is documentation.  Regardless of what happened in the exam room, documentation MUST meet CMS guidelines to bill varying levels of services.  Without appropriate and accurate documentation to support the level of service billed, providers are really opening themselves up for major issues with payors and very possibly the law.  As was mentioned in a previous post, today’s electronic health records (EHR) systems are highly intuitive and useful in hitting all of the necessary documentation markers.  Do NOT fall pray to templates and cloning.  Always document the unique aspects of each examination.

The speakers at the conference spoke extensively on correct E/M coding.  To code E/M’s properly, providers must be aware of three main components: history, exam, and medical decision making.  The level at which each of these are completed is what determines the level of service billed.  I must emphasize that wordy or over-documentation does NOT equate a higher level of E/M.  Because each component requires a great deal of consideration, I am only focusing on the history component in this post.

What does the history component in an E/M entail?  There are some important areas that should be hit to ensure that a history component is accurately and appropriately performed and documented. First, what is the chief complaint?  Document this in a clear and efficient statement, basically explaining why the patient is presenting for the visit.  Second, the history of present illness (HPI) should be performed and documented.  An HPI includes such things as when and where the injury or illness began to occur/appear, symptoms of the illness, when the injury/illness seems to worsen or get better, how often is it experienced and in what environments, etc.  Detail clearly the history behind the patient’s condition.  Third, past, family, social history (PFSH) should be addressed.  PFSH is pretty self explanatory, but includes such details as any family diseases, social history, such as smoking and alcohol use, etc.  Finally, a review of systems (ROS) is needed in the history component of the visit.  An ROS is as it sounds, a review of different bodily systems and part, such as the eyes, the heart, respiration, etc.  PFSH and ROS may be documented on a patient-completed form, but the provider must review this with the patient to ensure accuracy and to ask any questions that may arise.

Clearly coding E/M services is lengthy and requires special attention to detail, but doing so will result in not only more accurate and appropriate payor reimbursement, but will also help to maintain practice integrity and better patient care.  MedPro Services is continually educating and informing our providers on appropriate and accurate E/M documenting and coding.  We strive to ensure that documentation meets CMS standards and is reflective of actual services rendered.  In the following weeks, I hope to address further aspects of E/M coding and how MedPro Services can help providers address any areas of issue or concern with the topic.  If you have questions on E/M coding or are concerned your current billing company is not performing up-to-par, feel free to send us a message detailing your questions and concerns.

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