February 16, 2024 | By Jennifer McNamara, CCS, CPC, CDEO, CPMA, CRC, COSC, CGSC, COPC, AAPC Approved Instructor | CEO, Healthcare Inspired, LLC
Beyond Box Checking
Compliance with reporting Evaluation and Management (E/M) services often takes center stage and has received much attention in recent years. They are the main revenue stream for Primary Care physicians, among others.
Some organizations look at them as just a box-checking methodology for reimbursement. It’s time we take a look at what Evaluation and Management services do beyond providing reimbursement.
The Real Purpose of E/M Services
Evaluation and Management services are not just about reimbursement. They tell the patient’s story so that other care providers can understand how to treat a patient. Each evaluation, each documented management decision, forms the patient’s narrative, shaping their care trajectory so where will they go next and why.
Bridging the Gap: E/M Services as a Management Process
Instead of viewing E/M services as a checklist based on AMA guidelines, let’s look at them as what they truly are- a way to manage a patient’s health.
What elements should be documented in every note regardless of reimbursement?
That is a question I often ask physicians when I provide auditing services.
I ask: What would you want your documentation to express if you could not speak to a specialist about your patient directly?
Most will respond with the following:
• A reliable history
• Documentation of their previous symptoms, surgeries, and diagnoses with status
• Medications they are currently taking
• Recent treatment provided and/or discussed.
Most auditors agree that these items are necessary and provide a clear picture. Unfortunately, much of this information is not provided in every patient encounter, leaving valuable data unseen that could change the course of a patient’s treatment and their health in general.
When missing pieces exist, physicians and others treating them will have to order more tests that have already been performed, unbeknownst to them. This creates more cost to the healthcare industry and exposes the patient to again another test that is not medically necessary when they had the same one two weeks prior.
Comprehensive documentation without burden
The adoption of value-based care models requires us to shift our thinking. Regardless of how reimbursement evolves, our focus should be patient-centric care. Elevating the standard of documentation within E/M services aligns directly with this. Clear, comprehensive documentation becomes the path to delivering personalized, quality care.
The burden of it all, though, is real. Many physicians and care providers feel overwhelmed with the burdens of documentation that meets the aforementioned standards.
Does this mean that when we say “Comprehensive,” we mean lengthy?
No. They do, though, need to be meaningful. While it is true that all providers document differently, It doesn’t mean that less isn’t more.
What areas of documentation in the Medical Decision Making process need attention?
- Prescription Drug Management: Documentation does not have to be wordy to be meaningful and relevant or to satisfy MDM Risk. What is needed is the drug being managed, the dosage, and its connection to a given problem addressed.
Why? This is because in order to be addressed, it is necessary to show how this happened. Essentially, the physician addressed the condition with “Prescription drug management.” - Review of a test: When ordering or reviewing an image or laboratory test, many record systems make it easy to copy and paste previous interpretations that do not belong to the physician of record. Simply stating, “ I reviewed all imaging and laboratory tests,” does not suffice. Documentation must support the tests you reviewed and the medical necessity behind them.
Remember, clinicians count the review because they want credit for their professional work. In order to do that, they need to show the test reviewed and tie it back to the problem addressed.
Evaluation and Management leveling requires two of the three areas to be met or exceeded for reimbursement, so from a payment and medical necessity standpoint, we definitely need to see the connection between the test and the problem addressed.
We also need to see the connection to show the thought process.
Then, subsequent care teams can understand that thought process and provide theirs. All for the benefit of the patient.
Independent Interpretation :
When identified as a data point, Independent Interpretation needs to show the test being interpreted beyond a simple review. Again, it does not have to be wordy, but identify the independently interpreted test and not just “independently reviewed.” There is a difference. They can simply review and restate what the radiologist said or discuss their “Independent” take on it. A provider’s Independent Interpretation shows they are using their own Independent reasoning to link it to the problem they are “addressing.”
These reminders will serve to elevate the documentation to support medical necessity and payment of services as well as tell the patient’s story through the professional thought process of a physician.
Effective Communication Fuels Quality Care
The future of healthcare reimbursement might undergo metamorphic changes, but one constant should remain—the commitment to providing exceptional care.
This commitment requires effective communication by well-documented E/M services. Regardless of how the financial landscape shifts, the patient’s journey should remain anchored in this communication among care teams.
If we audit E/M services, remember we are not just checking boxes; it’s about validating the documentation that supports the service with medical necessity as the overarching factor.
By understanding Evaluation and Management beyond reimbursement, we can reshape the narrative surrounding E/M services – from checkboxes to the truth of the patient’s story that leads to compliant reimbursement.
NAMAS is a part of DoctorsManagement, LLC, a medical consulting firm since 1956. They offer comprehensive auditing education, resources, training, and services. NAMAS has experienced auditors and educators with CPC and CPMA certification and over 10 years of auditing-specific experience. They have created the AAPC-affiliated CPMA credential and are the go-to authorities in auditing. NAMAS has helped numerous individuals grow in the auditing and compliance field.
