Good coding and documentation practices

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The difference between a financially and clinically successful practice and a struggling practice often comes down to whether the code is correct and thoroughly documented. Changes in 2021 to major coding categories, such as Assessment and Management (E / M) coding for office visits, mean a major change that can hamper your operations if not done right . Denials, one of the main points of aggravation of practices, are possible with any complaint filed, especially since each payer has their own policies, which are constantly changing.

What can firms do to tighten their coding and realize all the revenue they are owed?

Learning objectives

Understand the E / M coding changes and what that means for the end result.

Find out the most common reasons for claim denials and how to avoid them.

Meet the panelist

Bill Dacey, MHA, MBA, CPC, CPC-I, Director of The Dacey Group, Inc., a consulting firm specializing in physician coding and compliance

Coding and documentation of good practices

The E / M changes that went into effect in January were designed to simplify the process and can be a net financial gain for firms. Now doctors will select the correct level of care code based on the total time spent on the date of the encounter Where medical decision-making (MDM) – which is the most financially beneficial.

When it comes to E / M coding, Dacey recommends that practices understand the intricacies of time and MDM coding. (For a detailed breakdown, including coding tables, check out the full video and slide set at

Beyond coding these aspects correctly, the other problem for practices is that some of the categories of documentation that are no longer relevant to payment remain clinically relevant, notes Dacey.

“We know the story and review are no longer relevant to code selection, but you still have to do them for every encounter,” he says. “We assume that the note will always contain everything it needs from a clinical point of view. Some doctors have just abandoned it completely and have only one evaluation plan. It’s not really OK because you always have to have enough to support the clinical side of things, and it doesn’t tell the payer the whole story of that encounter either.

The good news for doctors is that Medicare payments for almost all E / M levels have increased. For example, Dacey reports that reimbursement rates have increased by 19% for code 99213, 21% for code 99214, and 23% for code 99215, which are level of care codes for established patients.

The key to successful coding under the new E / M changes is that documenting medical decision-making is essential, says Dacey, noting that payers look into the assessment and plan (A / P) to see if you have provided sufficient medical necessity to back up your claim. So be sure to do the following:

Document any specific differential diagnosis and any suspected issues or concerns that should be considered, excluded, etc.

Identify the diagnosis, status, prescriptions and treatments to manage each problem.

Characterize the problem – don’t just name it.

Introduce the litter in the history of the current disease, then present it in the A / P.

When it comes to how to avoid claim denials, Dacey says most denials are the result of basic errors such as filing duplicate claims, failing to verify eligibility, failing to review of prior authorization or failure to meet the deadline.

“There (are) a lot of ways to go wrong here,” Dacey says. “There (are) many ways to get denials very easily.”

The best thing that practices can do to avoid denials is to analyze common denials and use that knowledge to create better processes. “The number and types of rejections actually tell you where the weak parts of your machine are, which part of your operation needs to be more precise,” he says.

Dacey also points out that while some refusals are simple, others are incredibly complex and can affect downstream care, i.e. hepatic encephalopathy (HE). Due to changes in diagnostic coding during the transition to ICD-10 a few years ago, there is no longer a “pure” HE code; thus, incorrect coding of this condition leads to prior authorizations, which results in patients not receiving the care they need and ending up in hospital. The use of the recommended ICD-10 codes for HE patients who are in a coma (K72.91) or not (K72.90) is critical.

Dacey stresses that the key to a coding and documentation program that captures all revenue is not to look for ways to cut costs or small missed opportunities, but rather to get it right during the most frequent patient visits. more common than you have.

“Everyone is always looking for ways to cut costs and those little extra things you can do,” he says. “And I keep telling people, ‘Stop looking over there, and watch what you’re doing all day – and make sure you’ve got the right things. “

Solutions and takeaways:

Changes in 2021 to the coding of E / M office visits mean that medical decision-making and time are essential to get paid, but other aspects such as history of current illness, assessment and plan are still needed for appropriate clinical care.

Most refusals are caused by common mistakes, and the best way to avoid them is to have processes in place to report and remedy the most common reasons for refusals in your practice.

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