Evaluation and management codes

You have to write down every piece of information about your patient. Can we please just have meaningful patient-physician interaction without the compulsive documentation?

No, not if we are committed to providing quality care. After all, if your patient moves and has to switch dermatologists, your documentation will provide a vital foundation in the next stage of their care. You also need to document properly to get the correct payment.

What goes into a medical record?

Beyond describing the patient visit, diagnosis, and treatment plan, the medical record determines the level of E/M billing. It also provides a justification for what you did. It should make the case for the medical necessity of your services. (Seriously, it’s no fun when an insurer disagrees that a procedure was necessary, after you’ve already done it.) 

Avoid coding nightmares

To avoid coding nightmares, physicians should pay particular concern to a couple of common issues.

Medical necessity
Everything you document needs to be directly related to the diagnostic and treatment plan. It must be reasonable and medically necessary. Otherwise, you may be accused of "up-coding." For example, if you submit a code for a surgical procedure, but the information in the medical record shows that the patient could have been treated with a less invasive, non-surgical approach, then the insurance company may accuse you of up-coding. 

If the insurance company believes that you up-coded, they are not nice about it. At all. They may deny your reimbursement. If it occurs too often, they may begin to suspect insurance fraud. Sometimes, insurance may even go so far as to black-list a physician that they consider guilty of up-coding.

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Cloning
Cloning is when you copy and paste medical information from a previous note into a new one. It is a little like medical plagiarism. If you don’t update the cloned record to make it current and accurate, the patient's record will be incorrect and they may be billed for the wrong charges. That will not get you put on anyone’s holiday present list.

It’s easy to fall into the cloning trap. If your patient has a chronic condition and their visits are often very similar, cloning may save time. You may also accidentally clone if you fill out prompts and templates on electronic health records (EHRs) that automatically copy and paste for you. 

If you do go the copy and paste route to save some time, make sure that you at least update and edit the cloned entry to show changes to the patient’s condition or history. It should also show your work for that specific appointment, not for the mole you removed last year. 

There are a few times when cloning may be okay: 

• If your patient has a spot on her arm, and it is exactly like a spot she had a year ago, you could probably use some of the description from the first visit

• If the elements of a surgical procedure are nearly identical from case to case

• When tissue histology is nearly the same in various specimens, such as nodular basal cell carcinomas

Cloning should not be your default practice. From a quality standpoint, it can compromise the integrity of your patient’s medical record. From an ethical standpoint, it can lead to up-coding.

Test your knowledge

You can test your knowledge of E/M coding by taking a short Academy quiz, or see other coding quizzes.

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