March 24, 2023 | By Jennifer McNamara, CCS,CPC,CDEO,CPMA,CRC, COSC,CGSC,COPC, AAPC Approved Instructor | Director of Education and Coding, oncospark
When auditing medical charts, there are significant differences between evaluation and management services (E/M) and surgical services. These differences are essential to understand to ensure that the medical documentation is accurate, complete, and compliant with regulatory requirements. I hope these quick tips will help you in your auditing role.
- Documentation Requirements:The primary difference between E/M and surgical charts is the documentation requirements. In E/M charts, the documentation is focused on the elements needed to evaluate and treat the patient’s medical condition. The documentation must describe the patient’s symptoms, medical history, examination findings, and any diagnostic tests or treatments ordered.On the other hand, surgical chart documentation requires the surgical approach, the operative findings, the procedure performed, and any complications or postoperative care provided. It will of course also need to coincide with what the E/M visit identified as to the medical necessity of the given procedure.
- Time Spent On Chart Review:Another difference between auditing E/M and surgical charts is the amount of time spent on chart review. In reviewing E/M charts, the auditor will spend more time reviewing the patient’s medical history, symptoms, and examination findings. In contrast, in dissecting surgical charts, the auditor will spend more time reviewing the operative the surgical approach, intraoperative findings, and postoperative care to see how it aligns with the codes and payer requirements. It is important to track how much time it takes you as an auditor in order to identify the scope and effectiveness of your audit. For E/M services, depending on the level of complexity and the amount of documentation provided, auditing E/M services can take anywhere from 15-20 minutes per chart.Depending on the complexity of the surgical procedure, the amount of documentation provided, and the auditor’s experience and expertise, auditing surgical services can take anywhere from 30 minutes to several hours.
- Coding Requirements:The coding requirements for E/M and surgical charts differ significantly. E/M codes are based on the level of complexity of the patient’s condition, or possibly multiple conditions, as well as the thought process of the physician. What led the physician from the history they received to the point of ordering an xray or laboratory test? Then making sure they document their final thoughts related to the associated problem(s) with the expected outcome and potential risks.Surgical codes, on the other hand, require a different skill set. An auditor needs to know if the codes reported are clearly documented in relation to the reason for the service, and if it matches the approach used. There is also margin for error when it comes to any additional reportable services that may not have been initially captured that may result in a loss for the physician financially.
- Documentation for Compliance:Auditors must ensure that both E/M and surgical charts are compliant with regulatory requirements from CMS and other third-party payers. For example, the documentation for surgery must be compliant with any regulatory requirements related to the use of implants or the administration of anesthesia.Since auditing these services will require different skill sets and knowledge, take it upon yourself as an auditor to be familiar with the documentation requirements, coding requirements, and regulatory requirements for both types of services. By understanding these differences, you can ensure that medical documentation is accurate, complete, and compliant with the ultimate benefit of the patient receiving quality care due to a clear picture being seen by all care teams.
Your next steps:
- Contact NAMAS to discuss your organization’s coding and documentation practices.
- Read more blog posts to stay updated on the 2023 Revisions to the 2021 E&M Guidelines.
- Subscribe to the NAMAS YouTube channel for more auditing and compliance tips!
NAMAS is a division of DoctorsManagement, LLC, a premier full-service medical consulting firm since 1956. With a team of experienced auditors and educators boasting a minimum of a CPC and CPMA certification and 10+ years of auditing-specific experience, NAMAS offers a vast range of auditing education, resources, training, and services. As the original creator of the now AAPC-affiliated CPMA credential, NAMAS instructors continue to be the go-to authorities in auditing. From DOJ and RAC auditors to CMS and Medicare Advantage Auditors to physician and hospital-based auditing professionals, our team has educated them all. We are proud to have helped so many grow and excel in the auditing and compliance field.
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