Physicians consistently face claim denials on the reimbursement end of healthcare. Varying policies among payers, rules that often differ, and post-payment audits frequently lead to roadblocks. Physicians can optimize their chances of getting paid depending on what codes they assign and if they supply adequate supporting documentation. At the start of 2021, office visit evaluation and management (E/M) coding underwent significant E/M guideline changes. Physicians would benefit from familiarizing themselves with these new changes, as they may be unaware that they are either over-coding or under-coding.

Physicians should become familiar coding’s new time thresholds. Florida-based Alpha Coding Podcast series host and CEO Toni Elhoms, CCS, CPC, suggests that a typical physician coding error is to submit under code 99214 after meeting with an established patient for 25 minutes rather than submitting under code 99213. Deborah Grider, CDIP, CPC, a senior consultant at KarenZupko & Associates, Inc. in Chicago who is well known for her appearances on Talk Ten Tuesdays podcasts, stresses that it is of utmost importance for physicians to know when to bill based on time, as sometimes physicians end up with less revenue than if they chose to bill according to other factors like the complexity of the patient’s issues, the risk of morbidity and mortality, or the depth of analyzed data.

Making sure to accurately document all medical decision-making (MDM), without over-coding or under-coding, is another essential element. According to Michigan-based Joe Rivet, Esq., CCS-P, CPC, CHPC, CHC, CAC, founder of Rivet Health Law, PLC, physicians must make sure to document even brief assessments of chronic conditions. Furthermore, a physician’s thoughts regarding a chronic condition’s effects on a newly occurring issue must be included in documentation as well. Any assessment of the diagnoses plays a role in the MDM, as do the words used to describe the problem (ie, acute, systemic, life-threatening, etc.). Thorough, detailed documentation better positions physicians to get credit in the E/M for their work.

Rivet notes that not all labs and tests are considered part of MDM. Physicians ordering or reviewing unorthodox labs and tests that have their own CPT codes need to have a good grasp on how they contribute to the MDM or yet again risk over-coding or under-coding issues. Documentation of reviewing prior notes can also be included in the MDM, with each unique source considered individually. When social determinants of health (SDOH) have an obvious, clearly documented effect on a patient’s health, Rivet notes that they can be part of a physician’s MDM.

When it comes to COVID-19, Grider suggests that physicians gain a solid understanding of proper E/M coding. For instance, asymptomatic and symptomatic patients will have different E/M codes. Telehealth billing is another area in which physicians must educate themselves on the new E/M guidelines. They must consider certain requirements like audiovisual technology for certain circumstances, proper place of service code and modifiers, and providing proof of patient consent to show that the telehealth appointment did indeed take place. Rivet and Grider suggest that physicians have vendors update E/M templates to fit within the new E/M guidelines. Physicians would also benefit from hiring an external consultant to audit E/M records.