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You Should Worry about Medical Coding Guidelines Changing

You Should Worry about Medical Coding Guidelines Changing

Changes are coming with Evaluation and Management (E&M) coding guidelines. I will use this space to explain why these changes will be both a good thing and a challenge to physicians, particularly those who derive much of their income from office visits.

CHANGE IS OVERDUE

It has been 20 years since the 1997 E&M guidelines were promulgated. They were confusing to most physicians then and remain confusing today. One study from the Journal of Family Practice showed that physicians are accurate in their E&M coding only 55 percent of the time, yet Mitchell King, MD provided a fascinating follow-up investigation in the Archives of Internal Medicine that showed certified coding specialists agree on what the correct E&M code should be just 57 percent of the time! It calls into question how the afore-cited 55 percentwas derived.

Second, the guidelines have not been modified or clarified as healthcare has evolved. EHR usage by office-based physicians was well below twenty percent in ’97 — a 20 percent threshold was not reached until ’04 and surpasses 80 percent today. And all of us have seen what happens in an EHR world when physicians are documenting to oblique coding standards rather than documenting their care and care plan. The pearls that drive care and care coordination are hidden in an oyster bed of cut-and-paste and click-and-count documentation that serves no one.

Medicare considers it fraud when a physician over-codes. Medicare’s Recovery Audit Contractors (RACs), charged with finding said fraud in the healthcare system and being paid a commission of between 9 and 12 percent for finding fraud, have attacked physician overuse of high level E&M codes and pulled back millions when the documentation does not support the code. Other payers have followed suit, of course.

Physicians must bill patient visits using a 20-year old set of guidelines that were murky as hell back then and remain so. Physicians may be penalized for selecting the wrong code, and doing so is considered fraud…even though coding gurus disagree on what the right code really is! You can’t make this stuff up.

WHY CHANGE IS COMING

 

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