E/M Auditing 101 – Tips from an Auditor

June 19th at 11:00am EST

Even with the implementation of the Electronic Health Record (EHR/EMR) and their templates to click and paste your way to a particular level of E/M service, auditors continue to find frustration in E/M records that do not meet the level of service billed. If you are new to auditing, we will present basic auditing tips to help you perfect your expertise in the auditing field, and if you are a seasoned auditor, these shared insights will give you confidence that you are correctly interpreting the CMS and AMA rules of documentation.

  • Physicians shall code patient evaluation and management (E/M) visits with E/M codes that represent WHERE the visit occurs and that identify the COMPLEXITY of the visit performed.
  • Did you know that the history and exam from the 1995 E/M Documentation Guidelines are used with both the 1995 exam and the 1997 E/M guidelines? The 1997 E/M Documentation Guidelines provide the specialty examination guidelines only. The 1997 DGs enhanced the history component by adding a status of chronic conditions after implementation of the 1995 guidelines which is used in all services. We will explore the correct documentation language.
  • How is “Medical Necessity” considered when scoring a medical record during an audit? All services under Medicare must be reasonable and necessary as defined in “Title XVIII of the Social Security Act, Section 1862(a)(1)(A).” But we will take it a step further to simplify this answer.
  • In 2019, what parts of the History can be documented by the ancillary staff and beneficiary without repetitive comments by the physician? We will give you examples.
  • What is “the status of chronic conditions”? You will learn that the entry HTN or CHF as a chief complaint is not enough to support an HPI element. We will clarify that rule and language.
  • For the Examination portion of the E/M, can we combine both body areas and body systems? No. You must use one or the other in the 1995 E/M guidelines. We will give you examples so that there is no “double dipping” going on.
  • There is a misconception that “Prescription Drug Management” makes the entire E/M service a level “4”. Is this correct? No. This option is under the Table of Risk and you first need to know the definition of PDM before counting it under MDM.
  • What are the current criteria for using “Time” as the controlling factor for the E/M visit?
  • I’m confused on the scoring for when I review an EKG tracing, and bill for the professional component, but also want to capture the 2 points for reviewing the EKG under Data Reviewed. Can you clarify? Yes, we will clarify CMS’ position on this topic and how it relates to the audited record for compliance under MDM.

E/M Auditing can be subjective when interpreting many of the scoring methodologies, however we hope to give you a clearer path to a cleanly audited record that CMS would also agree with. Understanding concepts is the first key before giving auditing direction.

This basic Webinar will do just that and help you to understand what is necessary in 2019 to support a certain level of E/M service should you ever be formally audited. If you can support your documentation, and perfect your internal and external audits, you will stand above reproach with Medicare as we start to work toward 2021 and the new E/M model that has been proposed.

Presented by:
Terry A. Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, ACS-CA, SCP-CA, QMGC, QMCRC, Terry Fletcher Consulting, Inc

Click here for a recording of the webinar.
Presentation Slides