Automated E&M coding

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Automated E&M CPT coding

Background

All medical, surgical and procedural services rendered by providers can be identified by CPT (current Procedural terminology) codes (1). These are 5 digit codes that are used to document various services and levels of services provided. They are used for billing and other reporting processes. Evaluation and Management (E&M) codes describe patient visits in various venues; office, hospital, outpatient, emergency, observation. Each venue has several levels of service. These progress from a minimal visit thru to a comprehensive visit. There are elements of the history of present illness, review of systems, past, social, family history, physical exam, and medical decision making that go into assigning the levels of service. The key factors are history, physical exam and medical decision-making. Time can also be a contributory factor in determining a level of service.

Historically providers assigned a level of service or trained coders used the visit documentation to count elements, which are then used to assign a level of service. The level of service drives the work value and fee.

EHR Changes

With the advent of EHR , software programs have been developed that will count elements from the various categories. This generally requires that the data be placed in a structured form. The counting of elements can be displayed as a part of the record or may be calculated at the close of the encounter. The program may display color changes, a running count of the various elements or display a goal for the number of elements that need to be reached to score at a certain service level.

The Concern

These programs have been criticized as leading to higher encounter (E&M) levels by prompting providers to add documentation and “buff the chart” (2). CMS and other payers have raised concerns regarding a trend to higher levels of E&M service (3). They have at time been criticized as fraudulent by prompting the documentation of unnecessary information, included only to drive the E&M level higher.

Just a Tool

These software programs are simply tools and are not inherently bad or good. How they are used determines whether they are a benefit to a busy, harried provider or they are a way to manipulate the coding and billing process for profit.

A hammer, in the right hands, can be used to build a house; a home to protect and shelter a family. Alternatively, it can be used to bludgeon someone to death. The hammer is not evil or good but the person who uses it determines the outcome.

These software programs are a tool that can be used as a reminder to help document necessary information in today’s busy practice or can be an instrument that leads to unnecessary documentation and fraud.


References

1.American Medical Association official website: www.ama-assn.org.

2.The House of God, Samuel Shem, 1978

3. https://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf

Submitted by Mark Meredith,MD, FACEP