A significant portion of your practice’s billable services is probably comprised of evaluation and management (E&M) services. Unfortunately, E&M Codes documentation, or lack thereof, is one of the big reasons for claim denials. Many clinicians fail to make the connection between poor, incomplete, or inaccurate documentation and falling practice revenue. Here’s a closer look at some of the common problem areas that may result in denials, and information on how to fix these areas to reduce denials and increase revenue. 

Problem #1 – Illegible E&M Codes Documentation 

Two of the most important rules of coding include: 

• If it wasn’t documented, then it wasn’t done
• You can’t code something you can’t read

According to CMS requirements, it’s critical for all entries in a medical record to be legible. Any nursing notes, orders, progress notes, and other entries in medical records that aren’t legible can result in misinterpretation or misreading, which could lead to medical errors. 

It’s possible for claims to be denied simply because E&M documentation was illegible and was not able to be correctly coded. One of the best ways to fix this problem is to adopt a legibility standard for your practice. 

Problem #2 – Failing to Include CC, HPI, or MDM

Three essential components of E&M service include the patient history, physical exam, and medical decision-making. The patient history consists of the chief complaint (CC)of the patient, history of their present illness (HPI), as well as their past family and social history. Failing to provide documentation for the chief complaint, the medical decision-making, or the history of the patient’s illness could result in a denial. It’s important for providers to document these areas, and while ancillary staff may document the past, family, and social history and the review of systems as long as there’s a notation that this information was reviewed by the physician.  

Problem #3 – Failing to Document Orders for Tests 

The treating physician must be the one who orders all tests, such as lab tests, diagnostic x-rays, and other types of diagnostic tests. Tests that weren’t ordered by the treating physician aren’t considered necessary and reasonable and will be denied. The best way to prevent this problem is for practices to create templates for tests that are commonly ordered. Just remember that these tests must be validated with the signature of the ordering provider – the signature of ancillary staff will not be acceptable. 

Problem #4 – Forgetting to Document with Enough Diagnostic Specificity 

Especially since the implementation of ICD-10, it’s so essential to make sure that E&M documentation includes enough diagnostic specificity for services rendered. It’s also critical to ensure that codes being reported in claim forms are supported by documentation provided in the medical record. Failure to provide enough diagnostic specificity is a common cause for denials. Procedure and diagnosis codes need to be reported to the highest number of digits that are available for the counter. The code for the problem, diagnosis, condition, or reason for the visit that’s mainly responsible for services provided first. Any diagnoses that are documented as suspected, working diagnosis, questionable, or probable should not be coded. 

Problem #5 – Not Providing Enough Documentation to Code by Time 

Whenever coordination of care and/or counseling make up more than 50% of the encounter’s face-to-face time, it’s possible to use time as the main factor for deciding on the E&M service level. However, failing to provide enough documentation to code by time can result in denials. If you’re going to code by time, the documentation requirements include: 

• The total face-to-face time of the patient visit
• The total time of the coordination of care and counseling 
• The substance of the coordination of care and counseling 

Improving Documentation to Increase the Chances of Getting Claims Paid

Along with addressing some of the common problems with E&M documentation, there are several tips that practices can use to help improve documentation across the board to reduce denials and boost revenue. 

• Tip #1 – Foster Good Communication– Billing and coding staff should provide clinicians with feedback on the common reasons for denials. Monthly meetings or creating online groups can help foster this communication. 
• Tip #2 – Train Clinicians– Newly hired clinicians should be provided for training on the basics of the revenue cycle, proper documentation, and more. Teaching clinicians what they can do to prevent denials and support optimal billing can go a long way towards reducing claims denials. 
• Tip #3 – Leverage Technology– Many practice management systems and EHRs come with helpful tools that can help you find coding errors and generate reports on any recurrent issues. Check these reports regularly and work on the problem areas. 

Looking for more ways to reduce claims denials? M-Scribe, LLC can help. We offer professional medical billing and coding services to help your practice lower denials and increase practice revenue. Contact M-Scribe today to learn more about a customized solution that will fit the needs of your practice.

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