Many physicians do not know how to code. It’s hard to believe that a task that physicians execute many times each day is performed improperly over and over again. Pretty bold statement, but I have the evidence, at least as it relates to family docs. In 2001 the Journal of the American Board of Family Medicine published a study on the Accuracy of CPT Evaluation and Management Coding by Family Physicians. In general the study showed that physicians were chronically undercoding! It is counter-intuitive that doctors would be “cheating” themselves. There is of course a logical explanation. First of all, physicians are under-trained with regard to coding, especially Evaluation and Management coding. Doctors are usually not trained in medical school on how to code properly and when coding rules change they are too busy to enroll in billing classes. In addition physicians are terrified of over-coding. They abhor the possibility that they will be negatively profiled or penalized by insurance companies. Doctors recognize that insurance companies try to view their coding through the prism of the old-fashioned bell curve. Providers are resigned to the fact that no matter how hard they work and how much time they spend with a patient they can not bill E/M codes accurately for the excellent service they provide. Physicians are usually not shy about billing for their hard work, but why do they become timid with regard to E/M coding?
In 1997 CMS, the Center for Medicare & Medicaid Services published a 51-page guide on how to use CPT codes to bill the Evaluation and Management part of a patient encounter. That document presents the doc with a complex set of rubrics that an auditor could use to rate the level of an E/M visit. I have read this document and even if a doctor was able to process all of the information in that document at the point of care (which they can’t without a computer) I believe that the document still would not provide a physician with all of the data required to make the proper choice of an E/M code. What CMS “conveniently” does not include in the document is the auditor worksheets that a Medicare auditor would use to “rate” an encounter’s E/M value.
In our blog on Health Maintenance we spoke to the fact that issues like preventive care require multi-tasking during the patient encounter. Evaluation and Management coding falls into the same category; it is an additional task but surely not the primary reason why a patient is visiting with the provider. I never heard a patient say “Hey Dr. Jones can you make my medical problem better and also I’d like a 99215 code while you’re at it.” Thinking through the complex rubric associated with E/M coding “bites at the ankles’ of medical providers. Here is the logic that the provider must perform if they code E/M without the assistance of an EHR.
Skip this part if you don’t have that Starbucks on your desk that I often refer to
I just examined this patient and now I must code for E/M — I will start now:
There are 8 elements related to the History of Present Illness (HPI) — what elements did I ask about and how many did I perform? Next, there are 14 organ systems to review with the patient — Review Of Systems (ROS) — how many did I review and are they all documented in my note? There are three types of other histories that I get credit for: Past Medical, Family and Social History (PMFS) — how many did I review and did I make a notation in my chart that I reviewed or updated them. There is a rubric of just the history portion of the note which includes the HPI, ROS and other histories PMFS — now I can rate the level of the history portion of the E/M coding. I am now just one quarter of the way there.
Next is physical exam. What parts of the body did I examine and did I document the way CMS wants me to — how many elements in each part of the body did I examine? I need to count them, make sure they are the elements I can claim “credit” for and compare them with another complex rubric the one designed for rating the level of physical exam. Half-way there.
Next is medical complexity —How much data did I review? What is the patient’s risk of morbidity or mortality? How many diagnoses does the patient have and how severe are they? Three quarters of the way there.
Finally I need to determine whether this is a new visit or an established visit and then take the values from the history, physical exam and medical complexity rubrics and place them in a final rubric to assist me on choosing an E/M code. Simple!
It is impossible for a provider to perform the above captioned analysis at the point of care. It is really unfair to the patient to require their provider to concentrate on these complex coding rules when the provider should really be focused on their care. Undoubtedly it is easy to understand why physicians under-code. They cannot be accurate because they cannot process this amount of data at the same time they are caring for patients. They know they can’t be accurate so they under-code. Physicians need an EHR to track and count all of the elements that comprise each portion of the encounter and then compare them to the CMS rules. MediTouch EHR can do that in just seconds and then MediTouch can suggest the appropriate E/M code. If the care was performed MediTouch knows it and gives the provider “credit” for their hard work. No more under-coding, the suggested code will display in the procedure coding module of our system. MediTouch displays the entire calculation (how the code was deduced) and can assist the provider in understanding why an encounter meets the CMS criteria for a specific E/M code. There are times that doctors have provided certain E/M related services, but they neglected to document them in the encounter note, now they can add that documentation to the note and the system will automatically re-calculate an updated code.
We make coding simple and with MediTouch Evaluation and Management Suggestive Coding, providers can focus on patient care and let our automated tools do the rest.
Be sure to read our upcoming blog on other ways MediTouch works with your practice to suggest codes for procedures and diagnoses.