Tip #5: Document a clinically relevant history and examination.Īlthough the new E/M guidelines say history and examination do not count toward the E/M level, they are still important from a clinical perspective and to justify medical necessity, says Grider. A unique source is defined as a physician or qualified health care professional in a distinct group or different specialty or subspecialty, or a unique entity. When physicians review prior notes, they can count this toward the MDM, and notes from each unique source can be counted separately, says Rivet. Tip #4: Document review of prior external notes. The same is true for a quick strep test, CPT code 87880. This is a results-only test, and the AMA has clarified that physicians can count reviewing the results of this test as a data element in the MDM, he adds. The same is true for an electrocardiogram when the physician reports CPT code 93000.Ī physician orders a dipstick urinalysis and reports CPT code 81001. They cannot count the ordering of this diagnostic test as a data element in the MDM if the provider performed and billed an interpretation of the X-ray, says Rivet. This means ordering a CBC with differential only counts once toward the MDM.Ī physician orders a chest X-ray and reports CPT code 71046. According to the AMA, single tests with overlapping elements are not unique even when those individual elements each have their own distinct CPT codes. This test includes hemoglobin, CBC without differential, and platelet count. A unique test is defined as one with its own CPT code, and physicians must understand whether and how the ordering and reviewing of these labs or tests can be used as a data element toward the overall MDM.Ī physician orders a complete blood cell count (CBC) with differential. Ordering and/or reviewing unique labs or tests is another area rife with compliance vulnerabilities for over- and undercoding, says Rivet. Tip #3: Know what labs and tests count toward the MDM. This includes using terms such as acute, systemic, chronic worsening, exacerbating, severely worsening, and threat to life or body function, she adds. It adds to the complexity, and they’re doing work they should be compensated for.” However, simply documenting that another professional is managing the problem does not count toward the E/M, he adds.īe sure to document the complexity of the problem addressed, says Grider. “Physicians should document this so they can get appropriate credit in the E/M. “If you do any type of assessment or evaluation around those diagnoses - no matter how slight they may be - then that can factor into the overall (MDM),” says Rivet. For example, they might briefly assess a chronic problem or think about the impact of that condition on the current presenting problem but do not document that thought process in the medical record. Physicians can easily under- or overcode because they do not accurately document their MDM - specifically the number and complexity of problems addressed, says Joe Rivet, Esq., CCS-P, CPC, CHPC, CHC, CAC, founder andhealth care attorney and arbitrator at Rivet Health Law, PLC, in Norton Shores, Michigan. Tip #2: Document all assessments you perform. “You don’t want to bill everything by time because, in some cases, you might be getting less revenue than if you had billed based on the complexity of the problems addressed, amount of complexity of data reviewed or analyzed, and risk of morbidity and mortality (i.e., medical decision-making ). Elhoms urges physicians to review the new thresholds below and update their billing practices accordingly.Įqually important is knowing when to bill based on time, says Deborah Grider, CDIP, CPC, senior consultant at KarenZupko & Associates, Inc., in Chicago. However, beginning in 2021, they should bill 99213 instead. One of the most common mistakes physicians make is that they try to bill 99214 when they spend 25 minutes with an established patient, says Toni Elhoms, CCS, CPC, chief executive officer of Alpha Coding Experts, LLC, in Orlando, Florida. Tip #1: Familiarize yourself with new time thresholds. Experts provide these tips to ensure accurate revenue capture. Experts say it is important for physicians to review this information because they may be over- or undercoding without realizing it. Office visit evaluation and management (E/M) coding saw some big changes this year, namely new E/M guidelines that took effect Jan. It all depends on the codes you assign and whether your documentation supports them. Just when you think you are in the clear, a payer decides to recoup that money. Then, of course, there are post-payment audits. Each payer has its own policy, and rules change frequently. The reimbursement side of medicine is filled with the potential for denials on every claim you submit.
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