Revenue Challenges – E/M Code Capture and Medical Decision Making

The CPT E/M (evaluation and management) coding system underwent some additional changes that became effective on January 1, 2023. If you are seeing revenue changes from the ED, this may be the reason.

Changes to the E/M coding system don’t just mean that the coding department needs education and updates – clinicians need to be changing the way they document as well. If your ED wasn’t quite ready for this or didn’t successfully implement the needed practices, then you might already be noticing some issues in the revenue cycle. Let’s take this opportunity to review E/M coding basics and some common costly errors.

Review of E/M Coding Basics

The evaluation and management code section (99202-99499) includes the following categories of service:

• Office or other outpatient services
• Hospital inpatient and observation care services
• Consultations
• Emergency department services
• Nursing facility services
• Home or residence services
• Prolonged service with or without direct patient contact, on the date of an E/M service

From there, each category is further subdivided into categories. For example, office visits are subdivided into two types: new patients and established patients. These subcategories are even further divided into levels of E/M services. The American Medical Association (AMA)’s Medical Decision-Making table serves as the definitive guide for selecting appropriate codes. The level of E/M service (as well as type) is an important factor to determine payment. Without proper documentation, levels can be misassigned, leading to improper coding and reimbursement.

The appropriate level of E/M service is based on the following three elements:

• The number and complexity of the problem(s) that are addressed during the encounter. Each problem has definitions that divide complexity into minimal, low, moderate, and high levels of complexity.
• The amount and/or complexity of data to be reviewed and analyzed. This includes charts, tests, and other sources (family, EMS, old records). Levels of data are also broken down into minimal, low, moderate, and high categories with specific definitions.
• The risk of complications and/or morbidity or mortality of patient management. The risk of complications (and morbidity/mortality) is divided into straightforward, low, moderate, and high groupings.

The final MDM code is determined by the level of service of TWO of the THREE elements. You may notice that if even one of the three elements has a level that is incorrectly assigned, then the entire MDM level can be off, contributing to revenue loss. Many physicians have found that they were habitually misassigning levels based on a lack of understanding of the definitions.

Common Coding Errors to Avoid

The following errors are listed by the AMA as common. Many of these can occur due to a lack of education on changes and misunderstandings, however, they can easily look like a fraud if they consistently work in the provider’s favor. It is always best to strive for accuracy, regardless of the payment outcome.

1. Unbundling Codes: Single codes often capture payment for an entire procedure, including the components. Using multiple CPT codes for individual parts is not allowed in these cases.
2. Upcoding. It is important to go through the three elements of MDM each time, and to avoid habitually coding certain levels based on the types of patients you normally see. For example, specialists such as oncologists frequently see very high complexity, high-risk patients – but that may not always be the case.
3. Improper reporting of infusion and hydration codes, which are time-based. Accurate documentation of start and stop times is essential for coders to properly bill for these services, including those that span over multiple days.
4. Improper reporting of injection codes. This code can only be used once per session, even if multiple injections take place.
5. Overusing modifier 22, Increased Procedural Services. Proper documentation must be included to explain why the procedure requires more work than usual. For instance, if a surgical excision is performed on a patient who is obese, making the procedure more time-consuming and difficult, then those details must be charted to increase the complexity.

Revenue cycle management is complicated – we get it. If you find yourself needing an expert partner to handle denials, AR recovery, revenue cycle efficiencies, and revenue cycle staffing, or you want to explore outsourcing options, let Healthrise be your first stop. We offer a range of services to fit healthcare needs and empower organizations to reach higher levels of financial health and stability. Contact us to learn how we can help.