decisionhealth Newsletters, Part B News - 2011 Issue 3 (March)
4 tips to reduce established E/M denials as carriers begin using tougher standards
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Article Overview
This article is about payer review of established evaluation and management services and the documentation issues that can lead to denials under stricter medical necessity standards. It is intended for physicians, coders, auditors, and practice managers who work with outpatient E/M documentation and appeals. The discussion focuses on audit findings, common problem areas in the record, carrier expectations, and broader trends in review intensity.
Why This Topic Matters
Established E/M visits are among the most frequently billed office services, so changes in payer review standards can have a large impact on denials, compliance risk, and revenue. Understanding the kinds of documentation issues highlighted in the article helps practices improve internal auditing and prepare for stricter carrier scrutiny.
Article Sections
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Audit findings and carrier review context
This section summarizes the payer review that prompted the article and the overall denial patterns observed across the sampled claims. It also provides context on the carriers and jurisdictions involved.
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Common documentation problem areas
This section outlines several broad documentation shortcomings identified in the review and discussed by the article’s sources. It focuses on recurring charting and record-completeness issues for established office visits.
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Stricter standards could be the new norm
This section discusses the possibility that more demanding review standards may continue beyond the specific audit described. It also addresses how practices may need to adapt their internal review processes.
What You Will Learn
- How payer reviews can affect established evaluation and management services
- Which broad documentation areas are commonly reviewed for denials
- Why chart completeness and medical necessity documentation matter
- How practices may respond to stricter audit expectations
- Why appeals and self-auditing can be important in denial management
Who Should Read This
- Physicians
- Medical coders
- Clinical documentation staff
- Practice managers
- Compliance and audit personnel
Codes Discussed
Code Ranges Discussed
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