There’s much confusion regarding current procedural terminology (CPT) codes for evaluation and management visits and how to use the codes properly. Physicians may have trouble understanding how the Evaluation & Management (E/M) coding system works, which could lead to incorrect documentation of the code they choose.

Physicians have a tendency to “downcode” when they’re unsure which code is applicable. This means they choose a code that presents a patient’s condition at a lower severity than it actually might be.

The three components that need to be considered to select the correct code are: history, examination, and medical decision-making. Within those components are further levels of complexity, which are determined if the following information is available or left undocumented: chief complaint, history of present illness, review of systems, and past, family, and/or social history.

Medical decision-making is the most difficult to classify as it’s a more subjective matter than the other two. In a Medical Economics article, Dr. Jeannie Engel, who lectures on coding for the American College of Physicians and is an associate professor at University of Utah School of Medicine, recommends documenting the patient’s medical issues during the visit, as many common things providers do are often undocumented. It’s also common for physicians to downcode a patient because they’re familiar with them.

CPT editorial panel member Boyd Buser suggests that electronic health records may be a factor in the opposite problem: “upcoding”. This can be even riskier than downcoding, as it could draw undeserved revenue, lead to audits, and cause unnecessary issues.

According to a May 2014 report by the Department of Health and Human Services Office of Inspector General (OIG), in 2010, 55% of E/M claims were coded improperly and/or didn’t have proper documentation, which resulted in $6.7 billion in inappropriate Medicare payments. The report found that, of the 42% of miscoded claims, 26% were upcoded and 14.5% were downcoded.

Author: Apoorva Anupindi

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