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E&M Utilization and Compliance

Does your documentation support the level and type of care you have provided? The Center for Medicare and Medicaid services (CMS) require E&M compliance with federal regulations. Providers must properly document patient encounters. The inability to correctly document encounters can often be attributed to a lack of knowledge. Emphasis should be placed on understanding the three forms of E&M utilization and how to achieve or sustain compliance.

The three forms of E&M utilization are: intra-category (level), inter-category (type), and global category utilization. All three contribute to analyzing E&M patterns. However, this article will only address specific aspects of intra and inter-category.

Every encounter requires documentation for the level of care provided. Intra-category concentrates on evaluating specific patient encounters. Five codes are used to document the level of care for New, Established and Outpatient Consultation office visits. Established office visits are coded 99211-99215. 99211 is the lowest level of care and 99215 is the most comprehensive level of care. Higher codes equal higher charges as well as higher documentation requirements.

Improper E&M coding for levels of care cause problems for medical practices. Problems stem from under and over coding. Under coding will cost a practice earned revenue. Over coding makes the practice vulnerable to third party reviews. The level of care provided is as important to understand as the type of care provided.

Inter-category utilization focuses on analyzing category relationships. One example of a relationship is Consults vs. Referrals. Providers do document encounters erroneously. Consults and Referrals are coded and documented incorrectly because of uncertainty on how to differentiate them. The type of care for E&M services (History, Examination, and Medical Decision Making) needs to concurrently justify invoices and provider documentation to maintain compliance.

Therefore, it is important to understand the definition of a Consultation in order to distinguish it from a Referral. Consultations are a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by a physician or other appropriate source. Referrals occur when a physician transfers responsibility for a patient.s complete care to the receiving physician at the time of the referral. Approval of care must be documented in advance for a consultation to occur.

The principle issue to be answered is whether there is a transfer of care at the time a patient is seen by a consulting provider. An example of a transfer of care is when a patient is seen by a family practice physician with complaints of wrist and hand pain, finger numbness and is suspected to have carpal tunnel syndrome. It is recommended to the patient to seek a hand surgeon's care and treatment.

Independent chart reviews are the best way to determine if providers are in compliance with E&M documentation guidelines. Performing a Comprehensive Medical Practice Analysis identifies E&M Utilization of a practice.

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