Cracking the Code of Evaluation and Management Documentation

Judging by the number of nodding heads, knowing glances exchanged among seatmates, and the long line of physicians waiting to ask questions and share their stories of frustration, Emily Hill’s Thursday presentation on the role of medical necessity in E/M coding was a rousing success. Her detailed yet concise rundown of the CMS documentation guidelines for E/M coding, with their carefully delineated bullet points outlining the criteria practices should use to differentiate, say, level 3 from level 4 care, and all the rationales behind the entire process left my head spinning, so I can imagine the level of frustration and uncertainty this process must generate in practices that have to endure it every day and make sense of it in order to justify every medical decision they make if they hope to receive proper payment for their services (not to mention the ever-present threat of an audit should their coding patterns fall outside the norm).

As an outsider to all this, I was struck by the deep, eye-crossing complexity of it all, and the overwhelming potential for confusion and uncertainty generated by this process. When one considers the constellation of coding and billing consultants and advisors and the vast body of literature that exists claiming to have the secret to “simplifying” the coding process and maximizing reimbursement, it’s hard not to question whether the system is there to serve physicians or whether it’s the other way around. Hill’s website features additional helpful resources for physicians looking for coding information and guidance, including a collection of case histories and a document download center that features articles, evaluation and management tables, and other tools.

I was also struck by the number of questions from the audience that had to do with actions and services contributing to quality patient care regularly performed by physicians and their staff for which there is no discrete code for reimbursement. Informal polling of several audience members confirmed that providing care often means performing a whole host of time-consuming but non-reimbursable tasks (everything from phone calls to third-party payers to helping patients fill out forms). It’s easy to see why some advocates are calling for a move to a time-based reimbursement model.

In the meantime, physicians are stuck trying to decipher the coding system.