Some institutions such as the E/M University and American Academy of Professional Coders (APPC) have provided tools to guide physicians with E/M codes and communication; in order to get an adequate compensation for their labor. The purpose of the paper is to identify the creator and purpose of E/M codes, and also to identify the three key components of E/M documentation. This paper will also portray the benefit of understanding E/M codes in practice, and it will point out some legal and ethical dilemmas encountered with the use of E/M documentation.
The purpose of E/M codes is to provide tools which will help educate physicians on E/M documentation and coding. Other than increased revenues, the E/M codes helps to improve documentation of patient data and alnico status. E/M codes were founded by the E/M University physicians and their intention was to help physicians effectively understand and utilize the E/ M codes in patient care. Hudson explains that E/M is the official abbreviation for evaluation and management codes, which is a method by which physician-patient encounter is transcribed into a five digit current procedural terminology (COP) codes (2014).
The COP code is a code with 5 numerals generated at each patient encounter. These codes are essential for billing in every step and it also describes the patients encounters with the physician. The three key components of E/M documentation are history, physical examination, and medical decision-making. The history Of E/M codes is a narration of symptoms and clinical 3 problems that were addressed in an encounter between physicians and patients (Hudson, 2014). In addition, the history comprises of four building blocks.
These building blocks include chief complaint (C), history of present illness (HIP), review of the systems (ROSS), and past medical history. History The C is usually the reason for the patient’s clinic or hospital visit. A C is compulsory every time the patient has an encounter with the physician. It ay be written in the patient’s oven words. For instance a patient comes into the clinic stating that his back is killing him. His C will be reported in the patient’s own words as “My back is killing me”.
Sometimes the C may be provided by the physician as a statement of the patient’s condition and their purpose of visit as reported by the patient (Wheezier et al. , 201 1 For instance patient States that he has back pain. The HIP is significant because it describes the symptom status and the problem they encounter clinically from the illnesses’ origin. The physician needs to fill out a HIP form in every encounter (Kismet & Godson, 2013). Additionally, the elements in HIP provide specific details on complaints. It also provides its progress to either being an acute or chronic problem.
Part of the history includes the location, quality, severity, duration, and timing of the problem based on the symptoms. The ROSS is used specifically by the physician while taking the patient’s history. The system is designed to showcase the clinical symptoms that the patient may have overlooked (Burns, et. Al. , 2012). Therefore, the system illuminates the information that the physician can use to diagnose the problem. The systems include eyes, respiratory, cardiovascular, endocrine, neurological, constitutional, gastrointestinal, genitourinary, genealogical, allergic, musculoskeletal, and psychological, amongst others.
The past medical history, family history, and social history comprises of the previous injuries and illnesses, allergies, operations, immunization status, current medications, dietary status, and prior hospitalizing. Each of these elements is considered as part of the past medical history (Kismet & Godson, 2013). History The past medical also includes immunization records, past hospitalizing, health promotion status, and family history. In addition, he past medical history elicits information about hereditary diseases and the patient’s vulnerability to obtain these diseases.
Physical Examination The physical exam for E/M codes comprise of four elements which are problem focused, expanded problem focused, detailed, and comprehensive. Interestingly, a physical examination involves being focused on the problem by being objective (Kismet & Godson, 2013). Traditionally, physicians had to use bullets but they now have a leeway to use any element or have it in black and white (Kismet & Godson, 2013). In a problem focused exam, the provider focuses on a maximum of five facets room one or more organ systems.
The Center for Medicare and Medicaid services (SMS) explains that in a problem focused exam the C is important and the HIP is brief. The ROSS and Family History are not very pertinent (2015). Johnson and Linker explain that in the Expanded Problem Focused exam, the provider focuses on at least six facets from at organ system (2013). The C is vital, the HIP is brief, and the system pertinent to the problem is important but the Family history is not necessary. 5 In a detailed exam, the provider focuses on at least two aspects from six organ systems. A detailed level exam requires a detailed history. The C.
C is required, the HIP and ROSS is extended while the family history is pertinent (SMS, 2015). In the comprehensive type exam, the provider focuses on at least two bullets form each of the nine body organs (E/M University, 2015). The C. C is required, the HIP is extended, and the ROSS and Family history is required. Finally, whether the exam is focused or comprehensive, its main objective must be to get as much information as possible about the patient health. Medical Decision Making Medical Decision Making has four levels which include; straightforward complexity, low complexity, moderate complexity, and high complexity.
The decisions made reflect the cognitive intensity of the labor the physician performs (Schmidt & Howell, 2010). For instance an established patient’s encounter is determined based on history, exam, and medical decision making. Desalt and Moore explain that the decision guidelines depend on the number of issues the physician or practitioner has to address at each visit. For example, the number of potential diagnoses and healthcare decisions to be made during an encounter, the number and involvements of data to be looked over, and the possibility Of complication, injury and death associated with the encounter (2010).
The straightforward level decision making is the lowest level in complexity and hence is hard to qualify (Derek-Smelts, et. Al. , 2014). It has a COP code of 99212 and it involves follows and/or routine encounters. In this level, the degree of risk is low whereby a patient with a chronic disease is stable (Derek- Smelts et al. , 2014). The must be a problem focused history, a problem focused exam with a straight forward decision. Usually the problem is self- limiting and is uncomplicated. For instance a patient with a history of osteoarthritis who comes In with knee 6 pain and is diagnosed with a flare-up and is prescribed over the counter
Motoring MGM as needed for pain. The low level complexity of medical decision making denoted by a COP code of 9921 3 is like a level 3 office visit. For a low complexity decision to be made there must be at least 2 or 3 key components with the risk and acuity being low. It must include a history of an expanded problem, an expanded focused examination with a low complexity medical decision. In other words there must be at least 2 problems and 2 data to be reviewed in order to make the medical decision.
For instance a Diabetic (DIM) patient with stable blood sugars who comes in for a routine visit and complains of allergic rhinitis as ell. The moderate complexity level is more like a level 4 office visit with a COP code of 99214. In other words, the patient’s condition is exacerbating mildly hence poses a risky element to the patient (SMS, 2015). For instance an established patient with diagnosis of DIM, Hypertension, hyperventilation’s all of which are controlled, comes in for a 4 month check-up and routine labs are done with no changes made to her medications.
Finally, the high complexity decision making level is the level whereby the patient is critically ill or the physician needs to reconsider primary data (Derek-Smelts et al. , 2014). It is a level 5 office visit with high complexities. This requires 2 to 3 components from 4 problems point and 4 data points to be reviewed to make a medical decision. The patient must have an exacerbation of an acute or chronic illness that could be life threatening for this level of complexity to be awarded (E/M University, 2015).
A comprehensive history together with a high complexity decision making must be present to award this level of care. The patient also needs unusual and consistent follow-up practices to monitor their progress. An example will be a 72 year old female who comes in with complaints of chest pain and a history Of myocardial Infarct, 7 uncontrolled TN, and DIM. The provider orders and reviews chest X-ray, Electrocardiogram, cardiac enzymes and determines the need for the patient to be started on a heparin drip.
Legal and ethical dilemma surrounding E/M coding and propose strategies for resolution The ethical dilemma surrounding E/M coding is encountered when a large clinic that is motivated by profit uses coding as an opportunity to make revenues. As a result, the encoding system receives more coded information than that which the actual documentations can support; moreover if this practice is intentional. Johnson and Linker explain that is unethical to use this type of practice to earn more revenue (2013).
In addition, the practice is against the American Health Information Management Association (ANIMA) code of ethics. For this reason, the coded information should go handy with the actual documentation to maintain ethical practices (Schmidt et al. , 2010) Following a similar scenario, it is illegal to have encoded data that does not match the actual documentation under the “briefing and encoding compliance strategies”. It is illegal because the coding does not comply with he regulations that clinics need to follow; as a result, individuals are liable to punishment under the Act.