We recently attended the annual meeting for the Carolinas Medical Directors Association in Charlotte, NC. One of the sessions focused on the challenges of billing for Medicare according to requirements set by the Centers for Medicare and Medicaid Services (CMS). Producing compliant notes and selecting the correct evaluation and management (E&M) code is a problem that vexes many practices today. Although the presentation was focused on the long term care environment, the information here should apply to most practices. We will focus on three main components: medical necessity, documentation requirements, and patient complexity.

Medical necessity is the most basic and important criteria. Each note should contain a rational, medical explanation for why you are seeing the patient. This is most often documented under the chief complaint. Physicians should be careful to use active verbiage in their notes. For instance, physicians should avoid using “reviewed” in favor of “assess,” and substitute “patient continues to exhibit…” instead of “stable.” Determine, measure, evaluate, verify, and examine are examples of good words to use. Use active voice in your notes instead of passive. For example, instead of saying “was reviewed,” state “I am instructing the nurse to measure.” The entire note should show the medical necessity of your visit and support the chief complaint.

In addition to medical necessity, CMS requires a certain amount of documentation for each E&M code. Generally speaking, higher levels require more documentation. Chief complaint is required for every level. Your note should have sections for history of present illness (HPI); past family and social history; physical exam and review of systems; and medical decision making. For example, an expanded level of coding generally requires at least four areas of HPI. Including information for each of these required areas can help you bill higher levels. If you are audited, CMS will look for each of these categories in your note.

Patient complexity is determined by risk and medical decision making. The more complex your patient is, the higher you can generally bill. For instance, if your patient suffers from an ingrown toenail, you won’t be able to code very high. On the other hand, if your patient has “one or more chronic illnesses with sever exacerbation or progression,” then you will qualify for a higher level. Also be sure to document work you do, such as reviewing or ordering lab tests, obtaining old records, etc. It can have a substantial impact on your coding and compliance.

Purchasing an electronic medical record (EMR) will help you code correctly and produce compliant documentation. Hand-written or dictated notes are often incomplete or illegible, but an EMR can help you fill out required information and pass an audit. In addition, an EMR can help you capture previously undocumented work you already perform. As a result, you can usually code at a higher level, leading to better reimbursements. If you are still using paper, now is the time to switch to EMR.

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Ryan Ricks

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www.XLEMR.com