Coding, Classification and Reimbursement

Coding E/M

  • 1.  Coding E/M

    Posted 19 days ago
    Are certified coders able to add E/M codes if the provider has forgotten to add E/M code in patient medical record? Or is the physician solely responsible for choosing E/M code? If certified coders are able to add/change E/M codes, is there a site i can reference to? Thanks in advance!

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    Irma Garcia
    Billing Specialist/Coder
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  • 2.  RE: Coding E/M

    Posted 19 days ago
    ​Hi Irma,

    I used to code for an urgent care and the provider would always upcode the E/M with the support from the visit to back up that level. Or they would undercode as well, a lot of the new PA's undercode (I've found). You can change them as long as the visit supports that level. There are numerous E/M level criteria charts out there to follow, just search E/M level criteria and things should pop up.

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    Brandy Giovanni
    Coding Specialist
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  • 3.  RE: Coding E/M

    Posted 19 days ago
    Irma

    I think the answer you are going to get is that it can be facility specific what they let you do. We assign E/M levels all of the time for the hospital and clinic side. The clinic side the providers are more responsible for it however if the documentation doesn't support the level the coders will change the level. I know other facilities where they are not allowed to change an E/M level without letting the provider know in advance.

    I'm not aware of anything site to reference except for the fact that coders are trained in ICD-10, PCS, CPT - it is our expertise. The provider should be taking care of the patient and documenting what they are doing and letting the coders do their part in choosing or verifying the levels according to the documentation.

    Good luck.

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    Beth Kosman, RHIT, CCS, CCS-P
    HIM Director/Privacy Officer
    Compliance Officer
    Ringgold County Hospital
    Mount Ayr, Iowa
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  • 4.  RE: Coding E/M

    Posted 19 days ago
    There are no rules that direct WHO assigns the EM code(s).
    I expect historically, most all physicians did their own EM coding and super bills/charge sheets contained diagnoses along with ICD codes.  Now; however, there are various watchdogs out there watching any/all improper payments, and risk adjusted payments make it imperative to employ a coder  - if not code all, but to oversee all EM assignments.  If they find reason for revision, it is encouraged to share the rationale with the physician to provide that educational piece.

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    Sheila Goethel
    Coding Services Senior Manager
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  • 5.  RE: Coding E/M

    Posted 19 days ago
    E&M coding is the physician's responsibility.  But, having said that, if the physicians chose to have a coder code the E&Ms, that is OK.  The physician is still responsible along with the coder for applying the correct E&M level.  This has always been a "thorn in my side".  A coder will apply the correct level based on the documentation which is what CMS will also do if they review charges.  What I have seen over the years is the physician, at the end of the patient visit, will assign a level based his thoughts at that time.  The physician may not dictate/finish the note until later that day.  Yes, some will finish the note immediately.  In order for a coder to accept this responsibility, they must have extensive E&M training, have the physician's OK with assigning the E&M levels.  The ideal situation is for the coder to work with the physicians to better document in order to assign the correct level.  As a coder, I can't nor do I want to practice medicine.  So let the physicians practice medicine and let the coders code.  Just remember you are keeping your physicians and yourself from wearing orange jumpsuits.  Anxious to hear other comments.

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    Nelda Laskey RHIT
    Coder/RAC Coordinator
    Kearny County Hospital
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