Evaluation and Management (E/M) coding is the number one source of revenue for the majority of providers in the U.S. Complex rules surround how to determine a specific code, making it nearly impossible to code correctly from memory. Electronic Health Records (EHRs) have the ability to store rules that can be applied to encounter notes (e.g., history and physicals and progress notes) and suggest an E/M code.
However, a small study conducted by Apollo HIT’s founder identified significant variances in the accuracy of E/M coding engines (see reference below). Relying upon an EHR to determine the E/M code without a thorough understanding of weakness of your EHR’s coding engine could lead to significant errors in coding. Based on this study, the majority of suggested E/M codes would actually be below what would be justified by what was documented in the encounter. The average physician who relies on an EHR E/M coding engine to determine coding levels is may be losing between $20,000 to $40,000 in revenue per year.
In some instances the EHR’s settings could lead to coding levels that are significantly above what would be justified by medical necessity and documentation. The most common source of EHR related overbilling for E/M codes is caused by “copy and paste” of information from other sources, templated defaults, and “padding” the diagnosis list in the assessment section of a note by pulling in irrelevant conditions from the problem list.
Apollo HIT has one of the most experienced physician coding professionals in the nation who has built coding engines for EHR companies, taught E/M coding to thousands of physicians, and presented on EHR E/M coding tools to the FBI, OIG and Justice Department.
We offer a low-cost program that will help you code accurately using your EHR, coupled with onging maintenance and internal (confidential) audits. We will benchmark your E/M coding levels compared with other practices and assess for per provider variances. Training, template customization, and a detailed analysis of your EHR’s coding capabilities are also included in this offering.
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1. EHRs and E/M Coding: Warnings, Pitfalls and Best Practices