Educate physicians and staff on proper E/M coding

Initiate communication between docs and coders

When Anita Orenstein, ART, CCS, CCS-P, health information services (HIS) compliance coordinator for Intermountain Health Care in Salt Lake City, found upcoding in evaluation and management (E/M) codes from an outsourced coding company, she recommended that the coding functions come in-house. (For more discussion on the problems of upcoding, see story, p. 161.)

Once they came under HIS control, Orenstein began to educate her coders on the proper way to arrive at an E/M code. Then she talked to the medical director of the emergency department (ED) so they could make a joint decision on how to involve ED staff in the E/M education process. "For the most part, I’ve found that they want it as a group."

She conducted a review of E/M documentation and met with a group of physicians to go over the records. "When we first presented them with this, they were very defensive and felt the codes were assigned appropriately," Orenstein says.

That reaction is not unusual, says Caren Reney, RN, CCS, owner and technical consultant for HealthCare Quality Consultants in Avon, CT.

"Physicians don’t like to be told about medical decision making. They just want a definitive answer about how to code at the two highest levels. Realistically, sometimes you have to say, If this is a patient who has a simple pneumonia, it’s inappropriate to code at that high level.’ They might not see it that way." she explains. "They will tell you what they had to do and what they wrote in the medical record. When you get into established patients in the hospitals, all you need is two out of the three criteria [to meet the requirements of that level]. So they are doing a history and examination to meet that requirement."

Spelling it out in black and white

The hospitals doing the best job are conducting group E/M education for physicians, which is an overall presentation based on some of the reviews the coders or auditors have been making, Reney says. "[The hospitals] are also doing one-on-one audits and one-to-one education with physicians. That seems to work because physicians believe that their specialty is unique and the things they are doing are unique, when in essence some of it is pretty standard."

Orenstein spent a significant amount of time with her physicians, breaking down the requirements for E/M documentation and comparing the requirements to documentation in the record. "When they see it in black and white, they come to an understanding of why those codes aren’t appropriate," she says.

In the medical record, physicians need to zero in on what distinguishes them from other health care providers, Reney adds. For example, medical assistants can complete a history — or patients can fill out their own in the waiting room. Nurse practitioners can do physical exams. "The only thing that is unique to a physician is medical decision making. That’s pretty well spelled out in the documentation guidelines and CPT. I know a lot of people consider it to be elusive, and that’s because it is geared simply for physicians at that level."

Establish a dialogue

Orenstein says she was able to establish a good dialogue with her physicians. Once they knew the guidelines, she talked about setting up regular communication between the physicians and coders. "If the physician is not documenting appropriately, you will never get the right E/M. It’s a partnership that you have to cultivate between the coder and the physician."

She suggests that physicians set up meetings with coders at whatever time interval works best for each facility — weekly, monthly, or quarterly. At these meetings, the coders bring records they find difficult to code, and the physicians explain their process of medical decision making.

"When you have a female of childbearing years complaining of abdominal pain, you have any number of management options available," Orenstein says. "The clinical points of reference that the physician can give the coder are helpful. Then the coder has to say, in this scenario, we need to have this information documented in the record.’ Together they can come up with a comprehensive document that’s going to support the E/M level."

Since the meetings began at her facilities, Orenstein says she has seen an improvement in the quality of documentation. "There is a greater understanding on the physician’s part on what’s really needed. You have to give the physician an active role to play," she advises. "On the clinical end, physicians need to make the coders understand their medical decision making thoughts, so the coders can better understand what’s in the record."

Nothing works individually as well as it does in a team, Orenstein adds. "If you can promote a good team atmosphere with the physicians and the coding staff, then you will have less frustration, a better-educated staff, and the best reimbursement you can from following the coding guidelines."