One of my payers is sending back a few dozen of our claims with the E/M codes downcoded from Level 4s to Level 3s. Is this common? Should we appeal?
Your first step is to establish that your physicians are in the right before considering an appeal. Don’t forget to keep the old saying in mind: If it isn’t documented, it didn’t happen. So make sure their documentation is tight before you even get started, Enos says. You should pay close attention to core E/M elements, such as history of present illness (HPI) and medical decision-making (MDM), to ensure your documentation is up to snuff.
Sometimes physicians simply just aren’t fully documenting everything they’ve done in an encounter. “You can’t just write, ‘I spent 30 minutes discussing options with the patient,’ in the documentation,” says Andria Jacobs, chief operating officer of PCG Software in Las Vegas. “You should rather say, ‘I reviewed these options with the patient,’ and then name them. Also, if the patient had concerns – about anesthesia, post-op care, whatever you discussed – name them as well. Then you can say, ‘These were the items that I spent 30 minutes on.’”
