Key Elements: Avoid 5 Common E/M Errors With These Expert Tips, Part 2

Why This Topic Matters

E/M coding mistakes can lead to denials, inaccurate reimbursement, and compliance risk. Understanding the documentation and reporting issues discussed here helps practices better align claims with the record and reduce avoidable billing problems.

Article Sections

1. Error 3: Halt Using 99213 as a Default Code

   Discusses the common practice of using a mid-level established-patient office/outpatient code as a default and why this can create billing problems. The section emphasizes matching documentation to the reported service level and educating providers about note quality.

2. Error 4: Keep an Eye on Notes Not Supporting Medically Necessity

   Covers the role of documentation and diagnoses in supporting medical necessity for billed services. The section includes a preventive visit scenario and explains the need for clear notes when multiple services occur during one encounter.

3. Error 5: Look for Support of Split/Shared Visits

   Explains documentation concerns related to split/shared encounters involving a physician and a non-physician provider. The section describes how these services are documented and billed in a hospital setting.