Watch for these common patterns of error in physician E/M leveling

By Joanne Wilson, RN, ADN, CCDS, Senior Director, Solutions

Challenges with accurate E/M level code assignments remain a persistent problem for providers. In my recent experience auditing across various specialties including behavioral health, critical care, internal medicine, and gastroenterology, I’ve found some consistent patterns emerge and am sharing with you.

Key observations:

• • E/M levels are often inaccurately assigned due to insufficient documentation. Providers can choose between medical-decision-making (MDM) or time-based assignments.

• • Documentation must align with the care provided for each diagnosis listed on the claim during the encounter, regardless of the chosen method.

• • Merely listing diagnoses without evidence of addressing the conditions fails to demonstrate medical necessity or support E/M level assignments based on MDM or time spent in care.

• • Assigning a CPT code 99215 with just one code of esophagitis doesn’t meet MDM guidelines for qualifying for 2 out of the 3 categories. Time-based assignments require a minimum of 40 minutes for the highest established patient CPT code. In this case, the patient’s follow-up visit without an acute exacerbation and OTC pantoprazole medication management didn’t meet this threshold.

• • Many providers still use the outdated 95/97 history and physical requirements. The updated 2023 H&P guidelines specify that an HPI stating the reason for the visit or relevant history is sufficient to demonstrate medical necessity, like “Patient follow-up for IBS-C.”

If your providers are struggling with accurate E/M level assignments, HCCs, staying updated on industry changes, you can make an impact by providing consistent education and messaging across provider specialties.

This is one of our areas of expertise. If you are struggling with any of the above issues, I’d love to talk to you about our unique solutions. Contact me at joanne@norwood.com