Evaluation & Management Part 2: The Exam

In continuation of the evaluation and management (E/M) series, this post will be on the exam, a part of the E/M that can vary greatly in extent and specificity.  At the recent Karen Zupko & Associates conference on General Surgery coding in Chicago, IL, a great deal of emphasis was placed on the importance of accurately documenting and coding the E/M.  The examination is one of the main components of the E/M, which was discussed at some length during the conference.  Depending on the patient’s presenting condition, the provider may determine at what level an exam is required.  An examination may be performed on numerous body systems, or it may be performed on the problem of focus and body part for which the patient is presenting.  Per CPT guidelines, a problem focused visit is usually just that, focused on the problem at hand, and a problem focused examination will be limited and directed at the impacted body part or system.  This varies greatly from a comprehensive examination, in which a provider will perform a more general evaluation of numerous patient systems (e.g. cardiovascular, respiratory, musculoskeletal) and organs.  It really all depends on how familiar the provider is with the patient’s specific condition and how much time and consideration is needed to determine the level of medical decision making.

As was mentioned in part 1, documentation is key.  Today’s electronic health records systems (EHRs) are especially useful in documenting the level of examination and on which body parts and systems and examination is performed.  Documentation may include such things as notating appearance, vital signs, or any assessment tools utilized during the exam.  These should all be documented and should be unique per the visit.  I have seen EHRs be very useful, but cloning can really affect the quality of documentation.  Providers must ensure that what is recorded is accurate for the specific visit.  For example, vitals from a visit two months ago should NEVER be included in a follow-up visit.  If these are going to be documented, then they must have been performed in that specific E/M.  Correctly documenting the examination portion of the E/M is critical because it plays a key role in determining which level of service to code (e.g. 99202, 99213).

I find that overall, providers do tend to code the examination portion of the E/M better than other portions.  That being said, as a medical biller and coder, I cannot emphasize enough how critical it is to correctly and accurately document.  MedPro Services strives to maintain coding and billing accuracy, but we cannot control a provider’s documentation.  We are, however, always willing and endeavoring to assist our providers in more accurate documentation, superbill coding, and other aspects of medical billing.  Please contact us with any and all inquiries, including consultation, coding,and billing.

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