Medicare Compliance & Reimbursement - 2013 Issue 37
E/M Coding: The Problem in This E/M Note Cost This Practice Over $65
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Article Overview
This article reviews a new patient evaluation and management note and discusses why the documented services align with a higher-level office visit than was reported. It also includes a brief primer comparing several new patient visit levels using simple examples to illustrate the general elements of history, examination, and medical decision-making. The piece is aimed at coders, billers, and other practice staff who review office visit documentation for accurate E/M reporting.
Why This Topic Matters
Accurate E/M level selection affects reimbursement and can prevent lost revenue from undercoding. The article is relevant to anyone responsible for auditing or assigning new patient office visit levels based on documentation.
Article Sections
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Know what you can’t miss when billing new patient visits
Introduces the focus on new patient office visit coding and the documentation elements that affect level selection.
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Did You Spot the Problems?
Presents a sample E/M note and discusses the coding issue identified in the review.
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99201 vs. 99203 Primer
Provides a comparison-oriented overview of different new patient E/M levels using short illustrative examples.
What You Will Learn
- How this article approaches review of a new patient E/M note
- Which broad documentation elements are considered in new patient office visit coding
- How comparative examples are used to distinguish among new patient E/M levels
- Why documentation review can affect reimbursement and coding accuracy
Who Should Read This
- Medical coders
- Billing staff
- Compliance auditors
- Revenue cycle staff
- Physician practice administrators
Codes Discussed
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