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CODING COACH: Follow 3 Tips to Navigate the Muddy Waters of E/M Coding

The doctor doesn't have to be in the house for your facility to bill E/M services, but to secure reimbursement for clinic and ED visits, you need to get nosy about her degree of patient involvement. Once you're sure of the physician's role, stay sharp on your facility's system of level assignment and find out what additional treatment the patient receives, and you'll code E/M services correctly every time.
Keep Tabs on The Doc
Unless you know how much the physician saw the patient, the other requirements for billing E/M won't matter. According to CMS guidelines, the hospital must provide these services with their own personnel, under a physician's order, and with physician supervision. This last element, along with the CMS Intermediary Manual's requirement that the hospital's services are "an integral though incidental" part of the doctor's treatment, is the least specific and causes the most confusion among coders.
Physician involvement doesn't need to be constant, but it must be consistent. "You can't have the doctor order a course of treatment and then no longer be involved," says Hugh Aaron, MHA, JD, CPC, CPC-H, president of Healthcare Regulatory Advisors in Glen Allen, Va., at a recent conference. While the doctor's presence isn't required at every patient encounter, she must see the patient regularly enough to monitor progress, determine whether the treatment is working, and change treatment if necessary. However, if you're furnishing the services off-site, the doctor must be there.
Know Your Hospital's Quirks
When you're choosing which E/M code to assign, remember that the most important guidelines to follow are those set up by your facility. Don't worry about whether your code corresponds to CPT requirements or to the code the physician bills, because the amount of resources your facility expends often differ from those of the doctor. In fact, CMS actually frowns upon defaulting to whatever code the physician picks, says Andy Ruskin, JD, associate at Vinson & Elkins law firm in Washington, DC, but since they haven't established more specific rules, they do not expressly prohibit this method. Ultimately, as long as your choices stick closely to your hospital's system, you'll get reimbursed according to the APC that covers your code. Since there are five possible E/M levels and only three APCs each for clinic and ED visits, codes for levels I and II will group as low-level visits (APC 600 and 610), III as mid-level (601 and 611), and IV and V as high-level (602 and 612).
Vital Signs Aren't Enough
When coding E/M services performed on the same day as nonE/M diagnostic services, interpreting CMS' ambiguous "significant and separately identifiable" [...]

- Published on 2003-04-01