Many doctors are confused by using the appropriate Evaluation and Management (E/M) code when reevaluating an established patient.
"I always do the exact same exam," they say, "so of course I use the exact same E/M codes!"
But consider this: a pattern of coding is a potential red flag, whether it's down-coding, up-coding, or repetitive coding. That's because when an auditor sees a pattern, what they're not seeing is a single piece of evidence that suggests you engaged in medical decision-making (MDM) instead of simply performing on autopilot.
According to the documentation guidelines outlined in the current procedural terminology (CPT), there are four recognized levels of MDM:
- Straightforward: minimal diagnosis and treatment, with simple or little data to be reviewed and minimal risk to the patient
- Low complexity: limited number of diagnosis and management options, limited data to be reviewed, and low risk of complications
- Moderate complexity: multiple diagnosis and management options, moderate amount and complexity of data to review, and a moderate risk to the patient of complications or death if left untreated
- High complexity: extensive diagnosis and management options, extensive or complex data to be reviewed, and a high risk to the patient of complications or death if left untreated
You don't have to cultivate patients in crisis in order to pass muster, but you do have to reflect in your documentation that you understand the distinctions above and code accordingly.
Repetition is convenient, easy, and familiar. But when it comes to E/M coding, it is most definitely not your friend.