Succeed in a Value-Driven Healthcare World

E&M services are easily recognizable medical services such as a visit to urgent care, hospital admission, or daily rounds on people admitted to a hospital. These services have multiple levels which correspond to different levels of medical complexity, such as a ‘new outpatient visit – level 4’. Selecting the correct level of service is critical to being paid appropriately for the patient encounter. Medicare released guidelines on how to select the proper service level in 1995 and 1997. These E&M Documentation Guidelines serve as the rulebook for E&M coding for physicians in the USA.

Not all medical services are covered under the E&M Documentation Guidelines. Surgeries, lab tests, preventative medicine, counseling, and imaging studies have separate documentation rules.

What needs to be documented for E&M services?

The 1997 E&M Documentation Guidelines state that each patient encounter must include a medical history, examination, and medical decision making (MDM). Each documentation component requires certain types of information to be documented in the medical record.

Documentation Components from the 1997 Guidelines:

Medical History

• Chief Complaint (CC)
• History of Present Illness (HPI)
• Past Family and Social History (PFSH)
• Review of Systems (ROS)

Physical Exam

Medical Decision Making (MDM)

• The number of diagnosis or management options
• Amount and complexity of medical data reviewed
• Risk of significant complications, morbidity, or mortality

This section discusses the challenges and complexity of E&M coding, particularly as it relates to selecting the level of service. Several published studies on the accuracy and expert agreement in E&M coding are discussed.

Despite challenges, E&M coding trends are evolving. Changes in E&M coding frequency in the Medicare population between 2001 and 2009 are discussed.

References for this section

Medical Decision Making: guide to improved CPT Coding

Expert Agreement in CPT coding for E&M Services

Evaluation and management services. A comparison of medical record documentation with actual billing in community family practice.

Accuracy of CPT evaluation and management coding by family physicians.

This discussion focuses on documenting medical procedures, which is much more straightforward than documenting E&M services.

This discussion focuses on how hospitals code for healthcare services with the DRG (Diagnosis Related Group) system and how your clinical documentation can impact this process. Effective documentation for the DRG coding process does not directly help physicians, but it can improve their risk adjusted quality metrics which can have long term benefits for individual physicians.

More effective DRG coding can have a major impact on the financial health of hospitals which results in significant benefits to the local community (jobs and access to healthcare to name a few).

This discussion covers how physician quality is assessed by a variety of programs including Medicare Value Based Purchasing and the PQRS system. These quality assessment systems are playing a growing and important role in how hospitals and outpatient practices are paid for medical services. This discussion will introduce you to the skills needed to excel in a quality and value driven healthcare enviroment.

This discussion focuses on physician employment contracting and covers key areas like noncompete clauses and signing bonuses.