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Module 7-Topic Paper-Debra Rabbani10/04/2023
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Debra Rabbani posted Oct 4, 2023 11:24 PM
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1. Consider the statement: If it is not documented, it did not
happen from the standpoint of making a claim for services
rendered. How is this relevant to the issue of coding E/M
procedures and services? [Tips: Coding is limited to the
documentation in the patient’s medical record. The medical
record is the documentation that supports a claim. If that
record is incomplete, the claim is not supportable. Consider the
highest levels of E/M services, patient histories and
examinations and complex MDM to diagnose and treat the
presenting condition]. What are some of the advantages of
using the CMS guidelines for E/M coding? The assignment of
codes from the E/M section is determined by three factors.
What are the three factors? [Tip: there are three types of
service included in the E/M section]. Why are these factors
[Tip: three types of service] important in coding procedures
and services in this section?
2. Two patients present with similar symptoms. Both appear
to be suffering from pneumonia. One patient is a 55-year-old
woman with controlled hypertension and diabetes; the other is
an otherwise healthy 24-year-old woman. How would the
examination levels differ for the two patients? [Tip: think
about patients in regard to dealing with histories,
examinations, multiple comorbidities, and levels of complexity
MDM (low-complexity, moderate-complexity, and highcomplexity MDM)].
A medical biller/coder cannot document a service that was not
performed. Only those procedures that are included in claims
submitted to the third-party payer. In the absence of
documentation, the claim cannot be submitted, and it is as if
the service/procedure was never delivered to the patient. A
medical record is a legal document that supports the claim for
services provided, and by providing false information about
services provided can be punishable by fines, loss of licensure,
or imprisonment. Many coders and coding managers in the past
have loss their positions and/or doctors losing their licensure to bill
Medicare and Medicaid and some other insurance companies due to
them authorizing coders to falsify information that is not documented
in the patient’s record or adding information to the patient’s record
that does not belong to the diagnosis. Falsifying information can
lead to a dishonorable reputation which can make a good
doctor lose patient’s which in turn will affect their financial
status and their once esteemed reputation. Many people rely on
government insured services, which they need, but cannot get
because the doctor dishonored his professional status by
authorizing their coders to falsify information to the
government agencies.
Evaluation and management codes are often referred to as
E&M codes or E and M codes. This is a coding system that
involves the use of CPT codes from the
range 99202 to 99499 which represent services provided by a
physician or other qualified healthcare professional. The three
key factors that affect evaluation and management codes
are history, examination, and medical decision
making- appear in the descriptors for office and other
outpatient services, hospital observation services, hospital
inpatient services, consultations, emergency department
services, nursing facility services, domiciliary care services,
and home health documentations. These factors are of utmost
importance in coding procedures and services because these
three factors give the insurance companies a narrative detail of
the patient’s problems.
It is advantageous for the medical biller/coder to follow the
CMS Guidelines for E/M coding. These guidelines help
summarize and organize material that is necessary for correct
E/M coding. To receive payment, skillful application of the
documentation guidelines must be followed in a clear, concise
manner. It is critical to provide patients with high quality and
safe medical care. By following the guidelines, selecting the
appropriate level of service will ensure the coder will receive
the maximum reimbursement for the healthcare services
rendered to the patients.
The medical decision-making elements associated with codes
99202-99215 will consist of three components: 1) Problem:
The number and complexity of problems addressed 2)
Data: Amount and/or complexity of data to be reviewed
and analyzed 3) Risk: Risk of complications.
Examples of Medical Decision-Making Codes:
An example is (99213) Office or other outpatient visit for the
evaluation and management of an established patient, which
requires a medically appropriate history and/or examination
and low level of medical decision making.
An example of an E/M code is (99214) Office or other
outpatient visit for the evaluation and management of an
established patient, which requires a medically appropriate
history and/or examination and moderate level of medical
decision making.
An example of an E/M code (99215) is evaluation and
management of an established patient in an office or outpatient
location for 40 minutes, which includes (1) a problemfocused history, (2) a problem-focused examination, and (3)
high complexity of medical decision making.
The examination levels would differ for both patients. The 55year-old patient is considered middle-aged and has many
comorbidities which require a more detailed assessment and
her case if of high-complexity MDM. She has a detailed
history of diabetes and hypertension and is now diagnosed
with pneumonia which could cause further issues with
pneumonia especially with their age, so an examination by a
specialist would be necessary to help provide an assessment of
the patient’s general condition before treatment. A diagnosis of
pneumonia could potentially affect her heart and her kidneys,
so the doctor should also assess her renal function, lung and
heart auscultation, blood pressure, blood sugar, breathing
pattern, and vital signs. Certain medications can spike blood
sugar and also spike her heart rate.
The 24-year-old patient presented to the physician with no
history of illness on her record, so the physician’s examination
will not be as comprehensive (low-complexity MDM) since it
would be classified as problem focused, since her pneumonia
is limited to the affected organ. Her age and health make them
a lower risk as well making examination faster. Her
examination would consist of checking her vital signs, her
breathing pattern, and auscultation of lungs to make sure she is
not hyperventilating.
Module 7 – Discussion
Contains unread posts
Ciara Stamper posted Oct 4, 2023 11:07 PM
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Ciara Stamper
10/04/2023
Please post a 3-page initial response to the following (A title page is not
required and please paste your initial discussion directly into your posting).
1. Consider the statement: If it is not documented, it did not happen from the
standpoint of making a claim for services rendered. How is this relevant to the
issue of coding E/M procedures and services? [Tips: Coding is limited to the
documentation in the patient’s medical record. The medical record is the
documentation that supports a claim. If that record is incomplete, the claim is
not supportable. Consider the highest levels of E/M services, patient histories
and examinations and complex MDM to diagnose and treat the presenting
condition].
a. What are some of the advantages of using the CMS guidelines for E/M
coding? The assignment of codes from the E/M section is determined by
three factors. What are the three factors? [Tip: there are three types of
service included in the E/M section]. Why are these factors [Tip: three types
of service] important in coding procedures and services in this section?
2. Two patients present with similar symptoms. Both appear to be suffering from
pneumonia. One patient is a 55-year-old woman with controlled hypertension
and diabetes; the other is an otherwise healthy 24-year-old woman. How would
the examination levels differ for the two patients? [Tip: think about patients in
regards to dealing with histories, examinations, multiple comorbidities, and
levels of complexity MDM (low-complexity, moderate-complexity, and highcomplexity MDM)].
Procedures that are documented will be turned into claims and
then sent to the insurance company for reimbursement. The procedure
codes provide information that informs the payer on which services and
procedures were rendered. If a procedure is not documented on the claim,
then it will not be submitted and it will be as if the procedure or service
never happened or occurred.
It is important that any service that is delivered to a patient is
documented, for legal and billing purposes. Accurate coding is very
important to ensure that billing is accurate, efficient, and compliant with
coding standards. Medical providers should thoroughly document the
patient’s medical condition and the reason why services were rendered to
treat the patient; they do this by following a set of guidelines and having
processes in place to ensure accuracy, such as an EMR system.
Any time that a patient is evaluated by a medical provider or is seen
for the management of a condition, an evaluation and management (E/M)
code is reported. This includes patient evaluations, such as annual exams
and lab work, and management of conditions, such as diabetes follow-up
appointments or medication checkups. These codes are used in all medical
specialties and all areas of healthcare including inpatient and outpatient
healthcare settings.
The assignment of codes from the E/M section is determined by
three factors: the type of service, the patient’s status, and the place
providing the service. The type of service describes the appointment
encounter, whether the visit encounter was a consultation visit, a hospital
visit, or telehealth appointment, and more. The patient’s status refers to
the patient’s actual status within the organization, whether they are a new
patient, existing/established patient, inpatient, or hospitalized. The place
of service indicates where the service was provided, whether it was in an
outpatient setting, an inpatient setting, a hospital, an office, or skilled
nursing facility, and more. These three factors are the key components
that makeup E/M codes.
If two patients came to the emergency room with similar symptoms
but are different ages and have different health and medical histories, their
evaluations and management of the condition would be different. An
older patient who comes to the emergency room with preexisting
conditions and now signs and symptoms of pneumonia would be evaluated
more thoroughly, to examine all previous conditions and new symptoms
presenting with the pneumonia. A younger, otherwise healthy patient,
who comes to the ER showing signs and symptoms of pneumonia would
have more of an exam focused on treating just the pneumonia. The older
patient’s exam will be thorough and focused on several factors and may
require many follow-up appointments. The younger patient will be treated
for pneumonia and may not require additional testing, although they will
be seen for a follow-up again to make sure that they are getting better.
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