July 21, 2023 | By Scott Kraft, CPMA, CPC
Whenever I audit charts under the 2021 E/M Documentation Guidelines, which now apply in all places of service, I like to start by reviewing the first and third columns. The first column is Number and Complexity of the Presenting Problem, and the third column is Risk of Complications and/or Morbidity or Mortality of Patient Management.
If I audit both categories to the same level of service, I’m almost relieved that I don’t need Amount and/or Complexity of Data to be Reviewed and/or Analyzed to help determine the most appropriate code. I find column 2, the “data” column as we shall call it, to be the most fraught and most subject to misapplication of misinterpretation.
The first reason is medical necessity and provider intent. Many EMR systems pre-populate notes, particularly in the inpatient setting, with all manner of test results and lab findings. The rendering provider may not even consider these items in his or her treatment plan and may not consider them relevant.
In addition, many providers state a preference for the patient’s historical lab and test results to be incorporated into each note for quick reference when necessary, even as these items have been ordered and reviewed in the past.
In these scenarios, we risk giving the provider credit in this category for something the provider may not even want to be credited with and raising the level of service beyond that which is medically necessary for the care of this particular patient.
In scenarios where I need data to help me select a code, I’ve given myself some things to consider as I navigate this category:
- Work on setting and communicating a data policy: Organizations should be thoughtful about how data is considered so that everyone in the organization is consistent with application of data. Examples of smart policies are asking/requiring providers to incorporate review of data/results into the formulation of the treatment plan and asking providers to designate when data is incorporated for preference and not scoring into the E/M result.
- Determine frequency of review: When a provider claims credit for an independent review of imaging or review of a test result, the provider should not get credit for the review again in a subsequent visit, as the results won’t change. One exception might be a comparative analysis of findings in order to determine disease progression when specifically documented.
- Determine need for review: Set or give guidelines to providers and internal auditors that data should be credited only when necessary for the rendering provider’s work and that the burden of establishing that need is with the rendering provider. Consider carefully MACRO statements that claim all new data was reviewed and incorporated into the treatment plan.
- Consider medical necessity: When the presenting problem is of straightforward or low complexity and the provider is ordering a high volume of lab tests for rule-out purposes or to placate the patient, but the patient’s overall care is not complex, remember what didn’t change when the new guidelines were implemented. Medical necessity, not the volume of documentation, should drive the code selection.
Your next steps:
- Contact NAMAS for information about customized staff and provider training.
- 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!
- Check out the agenda for the 15th Annual NAMAS Auditing & Compliance Conference and register to attend!
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