“If it isn’t documented, it hasn’t been done” is an adage frequently heard in the health care setting.
Medical record documentation requires recording pertinent facts, findings, observations about an individual's health history (including past and present illnesses), examinations, tests, treatments, and outcomes.
Too many physicians consistently undercode for their services because they do not comprehend E/M rules. A working knowledge of E/M coding is the best way to ensure optimal compliance and inadvertently avoid undercoding. Physicians who understand the idiosyncratic process of E/M documentation can command a higher rate of return on their cognitive labor versus their less E/M-savvy counterparts. In other words, if you understand how to accurately bill for your services, there is a better chance for receiving payment for what you actually do.
The CPT codes that describe physician-patient encounters are often referred to as “E/M codes.” There are a variety of E/M codes for different types of encounters such as an office or hospital visit. Within each type of encounter, there are distinctive levels of care. For example, the code 99214 may be used to charge for an office visit with an established patient. There are five levels of care for this type of encounter. The 99214 code is often called a “level 4” office visit because the code ends in the number “4” and because it is the fourth “level of care” for that type of visit ((99215 is the fifth and highest level of care). Each patient care encounter may be viewed as a unique procedure, requiring specific documentation.
What are E/M Services?
The three key components of E/M services, history, examination, and medical decision making appear in the descriptors for office and other outpatient services, hospital observation services, hospital inpatient services, consultations, emergency department services, nursing facility services, domiciliary care services, and home services. The descriptors for the levels of E/M services recognize seven components are used in defining the levels of E/M services. These components are:
The first three components (history, examination and medical decision-making) are key components in selecting the level of E/M services. In the case of visits consisting predominantly of counseling or coordination of care, time is the key or controlling factor to qualify for a particular level of E/M service.
Because the level of E/M service is dependent on two or three key components, performance and documentation of one component (e.g., examination) at the highest level does not necessarily mean that the encounter, in its entirety, qualifies for the maximum level of E/M service.