The administrator, generally familiar with the evaluation and management (E & M) coding issues, recognized that this letter was not in the ordinary course of business. The administrator spoke briefly to the president of the physician group and obtained permission to contact their billing consultant.

Short of a raid by federal or state authorities, a notice such as this is one of the most frightening issues a medical practice can face. E & M coding is a science with significant amount of art thrown in. The Medicare explanations of the various requirements for coding at each of the levels initially are straightforward. Nonetheless, the combination of day-to-day complexities, the time pressures that physicians are under, the time pressure and educational level of the billing staff, together with ever-changing regulations, makes the possibility of inadvertent errors in Medicare coding a greater likelihood than many physicians and practice administrators would like to admit. The ability to properly respond to a Medicare intermediary’s request for additional information with regard to the E & M coding decision-making process starts before the patient comes in the door.

A full-fledged training program for "all hands" is an absolute necessity. It accomplishes two purposes: (1) it allows all individuals, physicians and administrative staff who are involved with the billing process to understand clearly and concisely the issues the practice is facing and the type of patient information they will be reviewing, and (2) in the unlikely event there is ever an investigation or allegation of "up-coding" or over-billing with regard to E & M coding, the fact the practice has gone through a complete set of educational symposia will be a good defense against the idea that this could have been done intentionally.

Continually reinforcing the correct policies with follow-up training, and training of new employees as they are hired or promoted to a different set of responsibilities will go a long way towards limiting or eliminating errors in coding. While the risk is worst in an audit, don’t forget that errors in coding can go the other way - under coding - which can cost the practice real money in these very difficult times for physician practices. Good coding techniques and documentation methodologies can limit under coding, too.

The ability to differentiate the different types of history taken from the patient (problem-focused history, expanded problem-focused history, detailed history, comprehensive history, and problem-focused history) as well as the delineation of the different types of examination (expanded, problem-focused exam, detailed exam and comprehensive exam) when put together with the complexity of the medical decision-making (straight-forward, low complexity, moderate complexity and high complexity) will allow for the determination of the coding for the evaluation and management visit.

Determination of the E & M coding starts with the patient chart. The adage of "if it is not in the chart, it did not happen" must be kept in mind at all times by the physician, the physician extender or clerical staff member preparing the chart or electronic medical record. Coding will always start with a chief complaint, the history of the present illness, the review of symptoms and the past family and/or social history. The history of present illness (HPI) may be either brief or extended, depending on the circumstance. An extended HPI will include documentation of at least four HPI elements or the status of at least three chronic or inactive conditions. The review of the symptoms is generally considered to be an inventory of body systems, detailed with questions of the patient. The systems include the constitutional systems, eyes, ENT, cardio-vascular, respiratory, GI, Genitourinary, musculoskeletal, integumentary, neurological, psychiatric, endocrine hematological, lymphatic and the immune/allergic system. The review of systems will come down to one of the three types: problem pertinent, extended or complete. In the complete review of systems, there must be a minimum of ten body systems identified (with some exceptions) for specialty circumstances where in-depth review of a particular system may be substituted. The review of past, family and/or social history is required. There are two types of PFSH exams: pertinent and complete.

The examination is then detailed, as well. In the examination, both body areas and organ systems should be documented as to exam: head, neck, chest, abdomen, genitalia, back and extremity. The organ systems include eyes, ENT, cardio-vascular, respiratory, gastro-intestinal, genitourinary, musculoskeletal, skin, neurological, hematological/ lymphatic/immunologic and psychiatric system. The physician or physician extender will perform a general multi-system exam or an extensive single system exam.

The complexity of the medical decision-making is frighteningly more subjective, however, the Centers for Medicare and Medicaid Services (CMS) "Evaluation and Management Services Guide" discusses the medical decision-making thought process with regard to it being either straight-forward, of low complexity, of moderate complexity or high complexity including the number of diagnoses or management options that are considered, the amount and/or complexity of data to be reviewed, as well as the risk of significant complications, morbidity and/or mortality. In order for a visit to be considered of high complexity, there needs to be an extensive number of diagnoses and/or management options considered based on the history and physical; there needs to be an extensive amount and/or complexity of data being reviewed; and there needs to be a high risk of significant complications, morbidity and/or mortality.

The E & M Services Guide gives good examples that can be used for education as well as for internal critique for this evaluation.

In summary, the ways to avoid the accusation of up-coding or erroneous E & M coding submissions to Medicare include advance planning with the education of the staff, on-going maintenance of a system both for educating and monitoring physicians and other members of the staff who are involved in the E & M coding decision-making process, as well as a periodic internal and/or external audit to look at charts and all billing information to ascertain whether the charts fully document the E & M codes as submitted to Medicare. It is far better to catch any errors, whether inadvertent or systemic, in advance of any inquiry from an outside source, Medicare or the Office of the Inspector General rather than waiting for the letter to arrive at your door.