Don’t Let EHR Tempt You to Upcode E/M Services

Don’t Let EHR Tempt You to Upcode E/M Services

EHRs can assist with many aspects of E/M coding (like tracking for coding based on time), but the problem of reporting higher-level E/M codes without medical necessity is still around.

A recent article in Ophthalmology Coding Alert discussed the example of a doctor who billed almost all level-four and level-five E/M codes for established patients. He followed the prompts of his EHR to fill in information, leading to detailed or comprehensive histories and exams even when the patient’s case didn’t require that level of service. Here’s why that’s a problem and how you can avoid it.

Steer Clear of Loophole Thinking

You assign established patient office/outpatient visit codes 99212-99215 based on meeting the requirements for two of three key components: history, examination, and medical decision making (MDM). This “two of three” wording has the unfortunate habit of leading coders and providers to thinking that as long as they check off the boxes for higher-level history and exams, they can report higher-level E/M codes like 99214 and 99215.

The problem is that this approach doesn’t take medical necessity into account for code choice.

Medicare states, “Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT® code” (Medicare Claims Processing Manual, Chapter 12, Section 30.6.1.A). The manual goes on to state that billing a higher-level E/M when a lower-level E/M is warranted would not be medically necessary or appropriate, and the volume of documentation shouldn’t be the primary reason for your code choice.

In other words, meeting the exam and history requirements isn’t a loophole that lets you report higher-level (and therefore higher-paying) codes by ignoring medical necessity. (Why the focus on exam and history? MDM isn’t the same as medical necessity, but the nature of MDM — focused on the complexity of establishing diagnoses and selecting management options — can make the connection to medical necessity feel more direct. That’s why the exam/history combo tends to be more of a troublemaker for meeting medical necessity requirements.)

Ensure Both Providers and Coders Are in the Loop

Coding E/M services correctly requires a partnership between the coder and the provider because the provider is the one trained to determine medical necessity. The provider is the one who knows whether the patient’s individual case requires a higher-level exam and history. Coders know the coding rules and get to know their specialties well, but, in the end, determining and documenting medical necessity is the provider’s responsibility.

In clinical documentation improvement training, be sure providers and coders are both aware of medical necessity requirements and how to match documentation to the case. For instance, if your review finds the ophthalmologist is going into extensive detail on punctal plug patients’ genitourinary systems, it’s time for a discussion. Your coders may learn from the provider that there’s a clinical reason for an unexpected combo. Or the provider may reveal that the extensive documentation is the result of EHR prompts, leading you to decide it’s time to fine-tune your system, especially if the provider can’t exit the record without completing all the fields. In any case, you will have opened the conversation about what the documentation needs to include to define medical necessity and the appropriate E/M code level.

What About You?

What strategies have you found for ensuring your codes match medical necessity? What challenges have you faced?


Deborah works on a wide range of TCI SuperCoder projects, researching and writing about coding, as well as assisting with data updates and tool development for our online coding solutions. Since joining TCI in 2004, she’s covered the ins and outs of coding for radiology, cardiology, oncology and hematology, orthopedics, audiology, and more.

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