A doctor's guide to E/M coding

Key Points

Many coding articles have been written with the assumption that we physicians have a basic understanding of E/M coding guidelines or that-even without this basic understanding-learning a few tips will improve coding accuracy. For many of us, this assumption leads to more frustration and confusion. One reality that often is overlooked in coding education for physicians is that E/M documentation requires us to do something that we were never trained to do. In medical school, we are taught to document two things: a history and physical exam, and a subjective, objective, assessment, and plan, or SOAP, note. For the most part, our documentation is intended for our future reference, for communication with other providers, and to satisfy "the standard of care" imposed on us by the legal profession.

In contrast to how documentation is viewed from the medical perspective, documentation from an E/M perspective, as its history would suggest, attempts to translate into a payment level the amount and complexity of work we do. This coding perspective and its system of documentation are not taught in medical school and too often are not taught in residency. Similarities exist between the two ways of looking at documentation, but the origin and purpose are different.

If you deviate significantly from the national benchmarks, you likely will be audited. At least in theory, having a distribution of Current Procedural Terminology (CPT) E/M codes consistent with the national benchmark for your specialty should minimize the likelihood of a CMS audit. Even if your coding patterns match national benchmarks, however, it's still important to ensure that the coding accurately reflects the documentation. Nonetheless, the reality is that, over time, many doctors have been coding higher-level visits.

Perhaps electronic health record (EHR) systems and template use may help some doctors document higher-level visits, but decreased revenues may be putting pressure on all physicians to capture lost charges that previously would have been under-coded. Whatever is causing the trend, it is important not only to know how your practices compare with national benchmarks but to have a firm grasp on the fundamentals of E/M coding. To do so will minimize lost revenue and the potential to be audited and potentially charged with fraud.