E&M Guidelines: Taking a Close Look

Chronic or acute: questions persist in the new guidelines.

You know, we have been using the new evaluation and management (E&M) guidelines for 96 days now, and if they had the ease and efficiency, we were told they had, I don’t think we would still be stumbling over the questions that we get on a daily or weekly basis like we do.

I think if we were able to process the changes with the good intent in which the American Medical Association (AMA) made them, then of course, yes, we could, but I don’t think that same good intent is the one in which they will be processed at the level of the carrier. Is that due to malfeasance? Is that due to literal interpretation of the rules? Is it due to the old standby thinking of the carrier versus the physician?

The first column of the new medical decision-making (MDM) table, which is really the table of risk, is emblematic of the complexity of the presenting problem. There are multiple drivers in this column, but I think we would all agree that the main driver is whether the problem is chronic or acute. In the grading of the complexity of the chronicity and acuity, it becomes “easier” to reach higher levels of complexity for chronic conditions than acute conditions. AMA has now included a definition within the new guidelines indicating that a chronic condition is one the patient will have for at least one year, or until death.

So, now I ask you, my auditor friends, out there: is it incumbent upon the provider to prove this within the documentation? And let me add that I am not talking about when the provider says the patient has chronic back pain. In those instances – when the provider has diagnosed and documented the word “chronic” – we are good. It is when the word “chronic” is not documented, but rather inferred, that there’s an issue.

Let’s talk examples.

Say glaucoma or diabetes: the average person realizes that these are chronic conditions – that once a person has them, they have them. And while they may become controlled, they are lifelong conditions. Therefore, when the provider states that a patient has these conditions, I feel pretty confident that the carrier will count them as chronic conditions. However, how can I, from a compliance perspective, raise my “pretty confident” to “confident?” The history and present illness (HPI). While we don’t score history, it can complement the MDM, and having duration included would help define the chronicity of the problem.

What about a patient with hearing loss or lower back pain? These are problems that could be chronic or acute in nature. I will say one problem I have found in the these first 96 days with this new definition involves working with a physician with such an example. I tell them that for a patient they are managing for lower back pain, I will have to downcode, because they did not document that it is a chronic problem; the documentation of duration is less than one year, so therefore I have to categorize it as acute (there are not systemic or complicating factors to relate to the moderate category). However, it could be categorized (had the duration met the chronic factor) as a chronic, exacerbated problem that is being managed by increasing medication and sending the patient to physical therapy.

Herein lies the frustration. The AMA’s changes are well-intentioned, purposeful, and patient care-driven. But the interpretation that will be made from the verbiage listed will not be used in that same well-intentioned, purposeful way.

The moral of the story: be purposeful and well-intentioned in your documentation and tell the patient story, focusing on the SOAP (subjective, objective, assessment, and plan) note.

Print Friendly, PDF & Email
Facebook
Twitter
LinkedIn

Shannon DeConda CPC, CPC-I, CEMC, CMSCS, CPMA®

Shannon DeConda is the founder and president of the National Alliance of Medical Auditing Specialists (NAMAS) as well as the president of coding and billing services and a partner at DoctorsManagement, LLC. Ms. DeConda has more than 16 years of experience as a multi-specialty auditor and coder. She has helped coders, medical chart auditors, and medical practices optimize business processes and maximize reimbursement by identifying lost revenue. Since founding NAMAS in 2007, Ms. DeConda has developed the NAMAS CPMA® Certification Training, written the NAMAS CPMA® Study Guide, and launched a wide variety of educational products and web-based educational tools to help coders, auditors, and medical providers improve their efficiencies. Shannon is a member of the RACmonitor editorial board and is a popular guest on Monitor Mondays.

Related Stories

Confusion Reigns over Application of G2211

Confusion Reigns over Application of G2211

Although the effective date for billing Office and Outpatient (O/O) Evaluation and Management (E&M ) Visit Complexity Add-on Code G2211 was Jan. 1, the Centers

Read More

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Leveraging the CERT: A New Coding and Billing Risk Assessment Plan

Frank Cohen shows you how to leverage the Comprehensive Error Rate Testing Program (CERT) to create your own internal coding and billing risk assessment plan, including granular identification of risk areas and prioritizing audit tasks and functions resulting in decreased claim submission errors, reduced risk of audit-related damages, and a smoother, more efficient reimbursement process from Medicare.

April 9, 2024
2024 Observation Services Billing: How to Get It Right

2024 Observation Services Billing: How to Get It Right

Dr. Ronald Hirsch presents an essential “A to Z” review of Observation, including proper use for Medicare, Medicare Advantage, and commercial payers. He addresses the correct use of Observation in medical patients and surgical patients, and how to deal with the billing of unnecessary Observation services, professional fee billing, and more.

March 21, 2024
Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets

Explore the top-10 federal audit targets for 2024 in our webcast, “Top-10 Compliance Risk Areas for Hospitals & Physicians in 2024: Get Ahead of Federal Audit Targets,” featuring Certified Compliance Officer Michael G. Calahan, PA, MBA. Gain insights and best practices to proactively address risks, enhance compliance, and ensure financial well-being for your healthcare facility or practice. Join us for a comprehensive guide to successfully navigating the federal audit landscape.

February 22, 2024
Mastering Healthcare Refunds: Navigating Compliance with Confidence

Mastering Healthcare Refunds: Navigating Compliance with Confidence

Join healthcare attorney David Glaser, as he debunks refund myths, clarifies compliance essentials, and empowers healthcare professionals to safeguard facility finances. Uncover the secrets behind when to refund and why it matters. Don’t miss this crucial insight into strategic refund management.

February 29, 2024
2024 ICD-10-CM/PCS Coding Clinic Update Webcast Series

2024 ICD-10-CM/PCS Coding Clinic Update Webcast Series

HIM coding expert, Kay Piper, RHIA, CDIP, CCS, reviews the guidance and updates coders and CDIs on important information in each of the AHA’s 2024 ICD-10-CM/PCS Quarterly Coding Clinics in easy-to-access on-demand webcasts, available shortly after each official publication.

April 15, 2024

Trending News

This Leap Year, celebrate success with a 29% discount one day ONLY! Use code LEAP24 on February 29th at checkout to unlock this offer! Click here to learn more.
It’s Heart Month! Use code HEART24 at checkout to receive 20% off your cardiology products. Click here to view our suite of Cardiology products!