Does Your Documentation Tell a Story?

Perspectives From an Evaluation & Management Coder

As providers, we know you put a lot of time and effort into the care of your patients. We want you to get paid for every service you provide. But do your notes tell the full story of those services that you are providing?

In 2021 & 2023, Centers for Medicare & Medicaid Services (CMS), gave us new guidelines for reviewing notes and adjusted billing and coding guidelines to alleviate some of the “bean counting’ of years past.

Evaluation and Management services no longer rely heavily on the History and Exam portions of your notes. They still need to be documented to support medical necessity for the visit, but gone are the days of 4 HPI, 8 Review of Systems, 12 to 14 Exam points, and if you miss one you go back to the level 1 visit.

Current coding requirements assign a level to your Evaluation and Management based on medical decision-making or on the time spent treating the patient. MDM is based on the number of diagnoses & their complexity, the data ordered and reviewed, discussions of management and the risk of patient mortality.

When documenting a specific issue or chronic condition, we want to see the history or progression of that issue and where it is or what it looks like. We would also like to see that issue or chronic condition transition into the assessment and plan portion of the note. Remember the MEAT – Measure, Evaluate, Assess, and Treat, or DSP – Diagnosis, Status & Plan. These are what we look for in order to count those specific diagnoses and then determine your plan going forward.

Time is also allowed to be used in the coding of E&M visit. However, the documentation must match the time associated with the visit. A mismatch between documented time and the complexity of the visit will raise red flags. For example: Patient comes in to refill Metformin for DMII, and Norvasc for HBP. Provider documents: Long-term medication usage, Metformin & Norvasc refills sent to local pharmacy. Sent order to lab to recheck patient’s A1C. Counseled on DASH diet and exercise at least 30 min a day. Time spent with patient, 75min.

The alleged 75min in the visit note would raise a red flag given the noncomplexity of the visit. Your documentation should tell a story and that story should make sense to both your coder and to the payor.

Are you documenting in a way that gets you paid? Let us help you make sense of the new guidelines! Schedule a consultation with us at Triumph Medical Practice Solutions.