by Cheryl Nash
In 2021 we wrote an article detailing the changes to the Evaluation and Management (E&M) coding system set by the AMA to go into effect Jan. 1 of that year. (link to blog?) The changes were exciting in that they simplified the process of “scoring” an E&M and removed the tedious process of counting History and Physicial (H&P) elements. Instead, they went to a Time-based Model, or a Medical Decision Making (MDM) based Model.
In the intervening years payers have begun to scrutinize E&M coding more than in the past. We now receive numerous requests from payers for E&M Medical records in order to validate coding, and we see a fair share of denials. Most of these denials are directly related to the code level and the supporting documentation hinging off of the MDM Model.
MDM is…subjective. What one physician sees as a complex case, another may see as straightforward. Payers tend to lean towards the lesser code as a matter of default. Chronic venous insufficiency is usually a straightforward condition, and while it’s chronic and generally worsening when they present for an evaluation, it is still considered low risk which downgrades the code level. Claim reviews and claim corrections greatly increase the time and resources applied to any claim and an E&M’s value is reduced each time it is handled by your billing team. Additionally, once the payer has determined you are coding incorrectly, they will continue to ask for records complicating the process exponentially.
Time, however, is extremely simple and easy to validate with a few key steps in the practices’ work-flow and charting methods. Time includes all of the time involved in the patient’s visit on the day of their encounter. All you have to do is capture it.
The AMA has defined time as the total time spent on the visit on the DOS. This includes preparing to see the patient, reviewing separately obtained history, performing an appropriate examination and/or evaluation, counseling and educating the patient/family/caregiver, ordering medications, tests or procedures, communicating with other health care professionals (not reported elsewhere), documenting clinical information in the health record, independently interpreting (outside) test results (not reported separately) and communicating results to the patient/family/caregiver, and care coordination.
A link to the AMA Guideline can be found HERE.
The catch? All of this has to be done on the same day as the encounter. Delayed charting is excluded. In house Ultrasound performed on the same day is not included as this is reimbursed separately and includes interpretation and communicating results.
There is some confusion as to how this needs to be reported. You do not need to note every single item performed in order to obtain total time, but you do need to be specific enough to show that the time was tracked, that it was all on the same day, and your note needs to reflect this.
A generic sentence such as: > 35 minutes spent with patient will not suffice, exact times are needed. We see denials for this language from all payers.
A better sentence would be: At this encounter 22 minutes were spent face to face with the patient, with an additional 17 minutes spent pre/post visit to include coordination of care, reviewing records, and documenting in the patient’s record, and excluding the time spent on the patient’s diagnostic ultrasound = total time 39 minutes. All this is not to say that MDM cannot be used. You will want to select the highest code supported by the visit, however in our experience, time will still be the most commonly used methodology for providers in this specialty.