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Medical Documentation Challenges, Controversies, and Trends

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The difficulties with E&M coding, appropriate billing, and controversies over some of the E&M rules are discussed. Trends in coding over time and how that influences healthcare delivery are also explored.

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Medical Documentation Challenges, Controversies, and Trends

  1. 1. Practice Essentials for Physicians
  2. 2.  For E&M Coding, Understand Current  Challenges  Controversies  Trends
  3. 3.  Guidelines do not define criteria for  Number of diagnosis or treatment options  Amount and complexity of data reviewed  Each Medicare carrier has discretion in this area  Fortunately, most now use the same criteria
  4. 4.  When comparing 136 certified professional coders..Type of encounter Undercoded Coded Correctly Overcoded Established Patient 24% 59% 17% New Patient 8% 59% 33% This study compared E&M coding for 6 sample patient encounters by 136 certified coders with an average of 10 years of coding experience. The coding level with the highest level of agreement was considered the correct level. Overall agreement on coding level was 59%
  5. 5.  When compared to expert coders, FP physicians..Type of encounter Undercoded Coded Correctly Overcoded Established Patient 33% 51% 16% New Patient 1% 17% 82% This study compared E&M coding for 6 sample patient encounters by 198 FP physicians and professional coders. Coding by professional coders was considered to be accurate for the purposes of this study. J Am Board Fam Pract 2001;14:184-92
  6. 6. Undercoding is a major problem  An audit of 351 Family Practice notes showed… Undercoded 33% Based on audit of documentation Shows rate of actual undercoding. South Med J. 2010 Apr;103(4):316-22
  7. 7. Worse if just considering MDM  An audit of 351 Family Practice notes showed… Undercoded 50% Based on audit of MDM documentatio Approximates what could have been coded if properly documented in History + Exam sections.South Med J. 2010 Apr;103(4):316-22
  8. 8. Worse if considering presenting problem(s)  An audit of 351 Family Practice notes showed… Undercoded 80% Based on audit of presenting problem Approximates what could have been coded if properly documented for History + Exam + MDM South Med J. 2010 Apr;103(4):316-22
  9. 9. Example – Hospital Admission Initial Inpatient Evaluation CPT Code Medicare Allowable Charge RVUs Level 3 99223 $204 3.86 Level 2 99222 $138 2.61 Level 1 99221 $102 1.92 2014 Medicare Physician Fee Schedule, National Payment Amount, Accessed Undercoding by just one level reduces the Medicare Allowable Charge by 26-33%
  10. 10. 0% 10% 20% 30% 40% 50% 60% 99211 99212 99213 99214 99215 2001 2002 2003 2004 2005 2006 2007 2008 2009 Coding Trends of Medicare Evaluation and Management Services OEI-04-10-00180
  11. 11. 0% 10% 20% 30% 40% 50% 60% 99211 99212 99213 99214 99215 2001 2002 2003 2004 2005 2006 2007 2008 2009 Coding Trends of Medicare Evaluation and Management Services OEI-04-10-00180 Moderate MDM
  12. 12. 0% 10% 20% 30% 40% 50% 60% 70% 99231 99232 99233 2001 2002 2003 2004 2005 2006 2007 2008 2009 Coding Trends of Medicare Evaluation and Management Services OEI-04-10-00180
  13. 13. 0% 10% 20% 30% 40% 50% 60% 70% 99231 99232 99233 2001 2002 2003 2004 2005 2006 2007 2008 2009 Coding Trends of Medicare Evaluation and Management Services OEI-04-10-00180 Moderate MDM
  14. 14.  Set level with MDM  Document History/Exam to support level  Consider  E&M coding software  Documentation templates
  15. 15. Model used by 75% of practices in 2012/2013 Merritt Hawkins Survey
  16. 16.  Complex Rules  Consider  E&M Coding Software  Documentation Templates  Mastery of the rules relevant to your practice is essential for financial success

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