In the realm of medical coding, there is little room for error. Coding solutions, such as those used when noting specific procedures, such as surgeries and other treatments, leave little room for guesswork. However, this isn’t always the case with evaluation and management codes. These codes are among the trickiest for those who work in medical coding to master, despite being among the most common codes used daily. Knowing the mistakes that are most commonly made and how to avoid them is important in ensuring smooth everyday operations.
Recording Patient Histories
It seems as if it would make sense to document as much of a patient’s history as possible. This may not always be wise when it comes to evaluation and management codes. Over documentation can cause problems because unnecessary information can get caught up in patient records. For example, you may not need to code every diagnosis a physician suspects apart from as needed in the billing process. You do want to get the most accurate history possible, however; failure to do so can result in issues, such as the wrong levels.
Planning Ahead
The plan of care is critical in evaluation and management coding. This plan details everything from the instant a patient enters a physician’s care, including the initial consultation. This plan must also be clearly documented. It’s vital to remember coding professionals who look at a patient’s care record may not always be able to clearly see what has been done and what they need to code for.
If you would like more information on evaluation and management codes or are interested in an E&M coding tool, visit GeBBS Healthcare Solutions online or call by phone at 888-539-4282.
