General Surgery Coding Alert - 1999 Issue 10
Base E/M Code Assignment on the Level of MDM to Ensure Accurate Reporting
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Article Overview
This article discusses emergency department evaluation and management coding from the perspective of medical decision-making, emphasizing how auditors and coders approach chart review, documentation support, and level assignment. It is aimed at coders, billing staff, and emergency medicine compliance professionals who need a clearer understanding of documentation review practices and how they relate to accurate reporting. The article also addresses why the topic matters for avoiding undercoding, overcoding, and documentation problems in E/M reporting.
Why This Topic Matters
Accurate E/M reporting in emergency medicine depends on matching documentation to the level supported by the chart, particularly when medical decision-making drives code selection. Understanding this approach helps coding and billing staff evaluate documentation consistently and communicate documentation gaps to physicians.
Article Sections
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Bottom-Up Auditing
Explains the review approach used by auditors and how chart assessment begins with the overall level supported by the encounter documentation.
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Using This Method to Your Advantage
Describes how coders can apply the same review approach to evaluate documentation, support physician education, and recognize when chart support is insufficient.
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Code Selected Must Fit Presenting Problem
Focuses on the relationship between medical necessity, the encounter’s presenting problem, and the broader factors used to determine the service level.
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Process Makes Coders Job Easier
Addresses coder concerns about assignment errors and explains why a structured review approach can improve confidence and consistency.
What You Will Learn
- How emergency department charts are reviewed from the perspective of medical decision-making
- Why documentation support matters when assigning an E/M service level
- How coders can use chart review to identify documentation gaps
- How presenting problem and medical necessity affect level selection
- Why a structured review process can reduce uncertainty for coders
Who Should Read This
- Emergency department coders
- Medical billing staff
- Coding compliance professionals
- Emergency medicine practice managers
- Physician documentation educators
Codes Discussed
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