Are You Making the Deadliest E/M Coder Mistake?An audit tool can replace a physician in E/M Medical Necessity determinations; believing that is the #1 mistake you could be making.

You are awesome, but unless you are also a peer to the treating provider, you aren’t qualified to make a determination on medical necessity for E/M services. Due to the repetitive nature of documentation review in coding, a coder is well practiced in the analysis of the levels of service compared to the documented diagnoses. And, they are often able to identify possible irregularities and cases when Medical Necessity might be questioned.

A SOAP note is a documentation method employed by healthcare providers to create a patient’s chart. There are four parts to a coding SOAP note: Subjective, Objective, Assessment, and Plan. These all relate to the patient’s current condition in narrative form by the clinician. But, coding is NOT equal to the clinical SOAP note. Let’s look at why:

  • Subjective: Opinions. Medical Necessity is a clinically required action – it is the reason for a service and validates the provision of service. It is open for interpretation by all parties involved.
  • Objective: Facts. Medical Decision Making is a measurement of work. It is defined by the 1995 and 1997 Documentation Guidelines and the Marshfield Clinic audit tool. Due to these guidelines, a coder (or an EMR computer programmer for that matter) is able to calculate a technical level of service. Medical Decision Making is the mathematically formulated result of all documented components of the physician’s service, whether medically needed or not. It is the data driven outcome of a patient visit and not a substitute for determining the appropriateness of the services rendered or the Medical Necessity.
  • Assessment: Judgments. The best way to stay compliant with Medical Necessity related laws is to think of each element of the patient’s history and physical exam as a separate procedure that should be performed only if there is a clear medical reason to do so. This requires making a clinical judgement. A coder, while better educated than most non-clinicians, is not able to make that judgment with the certainty of a medical peer.
  • Plan: Strategies. You have to have one! In an effort to bridge the gap between the clinical savvy of a documenting provider and a clinically untrained coder some coding administrators have exchanged the definition of Medical Necessity with the Medical Decision Making (MDM) component of E/M services. This mistake that often leaves money on the table or results in over-payments.

So how can you fix that mistake? Coders must create a feedback loop that incorporates the clinical judgement of the E/M service provider. This is often accomplished by creating policies that can be used throughout the organization to ensure speed and consistency.

These should include:

  • Guidelines for clinical conditions that demonstrate probable service levels
  • Polices that protect against errors
  • Policies to do the ethical thing
  • Policies that can be understood and followed

Physician policies for effective communication in their documentation can also be helpful. For example, when documenting a patient’s condition in hospital rounds, “patient improving” might be more concise than “patient stable.” “Stable” indicates that the patient is in good enough condition to be discharged.

Physicians are on the front lines of care and are eager to collaborate with others who are interested in helping them tackle the problems that affect them. Effective communication comes from a coder who knows how to quickly discuss issues in a clinically meaningful way the physicians can relate to. This keeps them in the patient-centric world, and that is the art of medicine.