<img height="1" width="1" style="display:none;" alt="" src="https://dc.ads.linkedin.com/collect/?pid=152233&amp;fmt=gif">
❮ Back to Blog

Patient Documentation Evaluation and Management Guidelines for Medical Practices

by Jonathan Carr on December 4, 2017 at 3:10 PM


Using a set of guidelines for evaluation and management (E/M) documentation within your medical practice is important, and can lead to maximized practice revenues and a reduced chance for possible audits and fines that arise from miscoding. More importantly, communicating these guidelines to staff members, old and new, can result in a more streamlined, practice-wide process that ensures coding standardization.

Increasingly important under the Medicare Access and CHIP Reauthorization Act’s (MACRA) Final Rule, the focus on value-based care has increased the need for claims to be coded to the highest specificity to avoid reimbursement penalties. Creating a set of coding guidelines for E/M documentation is beneficial for revenue cycle management and general practice success.

Evaluation and Management (E/M) Documentation

When it comes to medical record documentation, the Centers for Medicare and Medicaid Services (CMS) has provided general principles of evaluation and management (E/M) documentation. These general principles help providers understand common sets of codes to bill for Medicare and E/M services provided by Medicare. In their guidelines, the CMS also provides helpful resources for E/M services that providers can use to further understand and standardize coding processes.

Related: Learn how to determine if your coding processes are undervaluing your medical practice's services.

According to an article published in Medical Economics, they suggest that physicians who create their own coding templates for E/M services should not assume that specific diagnoses justify a certain level of coding. They further suggest that providers document elements that support medical necessity rather than simply documenting a level of service.

This level of documentation allows for a higher quality of coding, resulting in decreased denials due to coding inaccuracies. Taking this philosophy and developing standardized coding guidelines for your practice not only benefits your revenue, but also maximizes your staff’s use of time as well.

Resources to Develop a Set of Guidelines

When coding for E/M and developing a set of guidelines, utilizing resources available can help greatly. Below are links to resources provided by the CMS that can help your practice effectively navigate E/M documentation for ICD-10, and get you started in creating guidelines specific to your practice.

The CMS also provides the 1995 and 1997 documentation guidelines, which are still in use today, that can further assist your practice in documenting E/M services to help you understand best practices pertaining to Medicare.

E/M documentation is a complex process, but using a set of guidelines within your medical practice allows providers to accurately code to the highest specificity for a variety of medical necessities, something that can greatly affect your practice’s future revenue and health.

New Call-to-action

Recent Posts

author avatar

This post was written by Jonathan Carr

Jonathan Carr is the Director of Business Development at Intermedix. Jonathan specializes in Revenue Cycle Management and Practice Management services to independent physicians and physician groups. Prior to joining Intermedix, Jonathan was the Regional Business Manager, Clinical Chemistry at ElitechGroup. Jonathan obtained his bachelor of arts degree in communication from Georgetown College.

Connect with Jonathan