Avoid assigning E/M codes based solely on documentation length

Coding an E/M visit based on the physician’s documentation is an art form -- but selecting a code simply based on the volume of documentation is just bad form. National Government Services (NGS), a Medicare payer in 26 states, recently published its "Post Pay Probe Results for Evaluation and Management Services" on its Web site.

The carrier noted that it downcoded subsequent hospital visit stays that several providers billed because the visits didn’t meet "policy documentation requirement guidelines." Interestingly, NGS indicated that some providers billed based on the amount of documentation rather than what the physician actually said in the documentation.

"The volume of documentation should not be the primary influence upon which a specific level of service is billed," NGS noted in its summary of findings.

The habit of coding based on the length of documentation is common. You should always base your code choice on the documentation’s content.

About the Author

Reed Tinsley CPA

This article is written by Reed Tinsley, a Houston, TX-based CPA with over 30 years of experience advising physicians and medical practices across Texas and the United States. Reed holds certifications as a Certified Valuation Analyst (CVA), Certified Healthcare Business Consultant (CHBC), and Certified Financial Planner (CFP), specializing exclusively in the healthcare sector. He is a published author, nationally recognized speaker, and trusted advisor to physicians on accounting & tax, practice management, and financial planning. Schedule a Free Consultation.