The revenue cycle for any medical practice heavily depends on the accurate documentation and coding of services. This is where an E&M Audit (Evaluation and Management Audit) comes into play. Ensuring the accuracy of E&M services can prevent financial losses, maintain compliance, and safeguard against audits from government bodies. Here are the 5 essential tips that can guide medical practices towards achieving success in E&M audits:
1. Understand E&M Guidelines
The foundation of a successful E&M audit lies in understanding the current E&M guidelines. These guidelines, set by organizations like the American Medical Association (AMA) and Medicare, dictate how patient visits should be documented and billed. Here’s what you need to know:
- Elements of Documentation: Know the history, examination, medical decision making, counseling, coordination of care, nature of presenting problem, and time as key components.
- CPT® Codes: Be familiar with the E&M code structure, especially the new patient codes, established patient codes, and the complexity of medical decision making.
- Key Changes: Keep abreast of any updates to the guidelines, which occur regularly and can impact how you document and code patient encounters.
📚 Note: Regularly refer to AMA’s publication or Medicare’s physician fee schedule for the latest updates.
2. Comprehensive Documentation
The mantra “If it’s not documented, it didn’t happen” holds especially true in the context of an E&M audit. Comprehensive documentation includes:
- Detailed Chief Complaint to explain why the patient sought care.
- Extensive History, which can be significant, pertinent, or reviewed.
- Examination results, documenting the relevant body areas or organ systems.
- The complexity of Medical Decision Making, from straightforward to highly complex.
📝 Note: A good practice is to document the specifics of each service rendered to support the level of service chosen.
3. Utilization of E&M Coding Tools
To streamline and improve the accuracy of E&M coding:
- E&M Calculators: These tools calculate the level of E&M service based on the documented elements. Using these can minimize errors in selecting codes.
- Compliance Software: Adopt software that helps with coding, tracking, and auditing documentation for compliance with Medicare’s 1995 and 1997 guidelines.
- Online Resources: Keep bookmarks to reliable coding and documentation resources like the AMA website, AAPC’s library, or CMS’s guidelines.
📱 Note: Regularly update software and online resources to align with the latest E&M coding updates.
4. Continuous Training and Education
Keeping your team educated and up-to-date is vital:
- Conduct regular training sessions to ensure staff are familiar with documentation requirements and coding practices.
- Subscribe to newsletters, join professional associations, and attend conferences for ongoing learning.
- Utilize online training modules that are specifically designed for E&M coding and documentation.
📅 Note: Annual refresher courses can help maintain proficiency among staff.
5. Audit and Feedback Loops
An E&M audit isn’t just about identifying issues; it’s also about learning and improving:
- Perform regular internal audits to catch errors early and provide feedback to practitioners.
- Implement a feedback loop where issues found in audits are communicated back to the staff for training and process improvement.
- Use benchmarking to compare documentation and coding practices against national standards or similar practices.
🔍 Note: Remember, the goal of an E&M audit is to improve the quality of care through better documentation and coding practices.
In summation, successful E&M audits require a blend of guideline knowledge, thorough documentation, efficient use of tools, continuous education, and an established audit-feedback mechanism. This holistic approach not only improves your chances of passing audits with flying colors but also ensures your practice is providing high-quality care to patients.
What are E&M audits?
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An E&M audit is a systematic review of the documentation and coding associated with Evaluation and Management services to ensure compliance with guidelines and accurate reimbursement.
How often should an E&M audit be performed?
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While there is no set frequency, many practices conduct quarterly internal audits and annual external reviews to maintain compliance and improve billing accuracy.
What should I do if an audit identifies problems?
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Use the findings as a learning opportunity. Train your staff, adjust documentation practices, and if necessary, consult with coding experts to address the issues.
