Q&A: E/M documentation traps

Q: What is an area to focus on when performing outpatient auditing for coding errors?

A: Evaluation and management (E/M) coding remains one of the highest-risk areas in outpatient auditing. Even well-intentioned providers frequently fall into documentation traps that don’t support the billed level of service, including:

• Incorrect level selection: Billing a high complexity visit when documentation supports only low or moderate medical decision-making (MDM) is among the most common and most scrutinized errors. This is something that is going to be scrutinized quite a bit and something coders want to slow down and take a look at and maybe even provide some education on.
• Time documentation deficiencies: If a provider is billing an E/M service based on time, it is absolutely essential that they clearly document the total time on that date of service. When there are things that are a little bit vague and it's not clear or explicitly documented, that could cause some issues.
• MDM inconsistencies: Each MDM element (i.e., problems, data, and risk) must collectively support the coded complexity level under AMA guidelines.
• Cloned or templated documentation: One of the things that physicians may do is copy-paste or copy-forward notes. Or they may even have electronic health record templates as a systemwide or an organizational process. These things are intended to lessen the administrative burdens that are placed on physicians and clinicians, but sometimes it causes replication of prior entries, and they may not even realize that this has happened. So, what happens is they unintentionally create significant compliance issues. Again, coders need to slow down, take a look at these things, and then provide adequate education on the proper use of documentation to avoid copy-pasting as much as possible and properly using EHR templates.
• Unsupported prolonged services: Prolonged service codes require meeting the base E/M time threshold first, plus documented additional time that clearly justifies the add-on code.

Editor’s note: This information was originally published by JustCoding, which adapted the information from Tatyana C. Mallory, MBA, RHIA, during the HCPro webinar, “Outpatient Auditing Bootcamp: Finding Errors Before They Find You.”