Medical Coding Service
E/M
E/M, short for “evaluation and management,” refers to the process through which physician-patient interactions are translated into CPT codes for billing purposes.
Some physicians consistently undercode their services due to a lack of comprehension of coding rules. A thorough understanding of our E/M coding team is crucial for ensuring optimal compliance and preventing unintentional undercoding.
Different E/M codes exist for various encounters, such as office visits or hospital visits, each comprising five distinct levels of care. For instance, the 99214 code is utilized to bill for an office visit with an established patient. Commonly referred to as a “level 4” office visit, the code ends in a “4” and represents the fourth “level of care” for that type of visit, with the 99215 being the fifth and highest level of care.
The E/M Guidelines
The documentation criteria for each individual E/M code are governed by a set of regulations known as the E/M guidelines. These guidelines were formulated collaboratively by the Center for Medicare and Medicaid Services (CMS) and the American Medical Association, with two versions released in 1995 and 1997. Based on client preferences, we adhere to either the 1995 or 1997 guidelines for coding and auditing E/M levels.
Key Components of E/M Documentation:
1. **History**
2. **Physical Exam**
3. **Medical Decision-Making**
These key components fulfill the documentation prerequisites for E/M coding, unless the physician is coding based on time. If time serves as the determining factor, there are no specific documentation requirements for the three key components.
HCC
The Hierarchical Condition Category (HCC) coding is a risk-adjustment model crafted to estimate the future healthcare costs of patients. This methodology involves accommodating chronic conditions, influencing the reimbursement amounts for health plans. The risk adjustment process assesses the clinical acuity of patients either concurrently, prospectively, or retrospectively.
As a leading medical organization, we incorporate four best practices to enhance our HCC coding performance.
Provider Education:
We engage in educating our providers on the importance of comprehensive physician documentation within the Electronic Medical Record (EMR). Emphasizing specificity ensures robust diagnosis coding, forming the cornerstone of successful Hierarchical Condition Category (HCC) coding.
Preparation for Each Patient Visit:
Physicians must proactively prepare for appointments with complex HCC patients to avoid overlooking crucial documentation. This proactive approach enables us to accurately and comprehensively address chronic conditions, capturing HCCs more effectively.
Utilization of Coding Experts:
Our team relies on Certified Risk Adjustment Coders (CRCs) to ensure the most reliable, consistent, and accurate HCC coding.
Real-Time Audit Reporting of Performance:
Risk Adjustment auditors utilize various tools, with MEAT (Monitor, Evaluate, Access, and Treat) and TAMPER (Treatment, Monitor/Medicate, Plan, Evaluate, and Referral) being among the most popular. MEAT aids coders in selecting supporting diagnosis codes for rendered services. On the other hand, TAMPER assists coders in addressing diagnoses presented in a list or described with a “history of.” By questioning whether the provider “TAMPERed” with a diagnosis on the Date of Service (DOS), coders determine its current status.
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