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You Should Worry about Medical Coding Guidelines Changing


E&M coding guidelines are finally changing after 20 years, but don't celebrate yet. These changes may be worrisome to practices

Changes are coming with Evaluation and Management (E&M) coding guidelines.   I will use this space to explain why these changes will be both a good thing and a challenge to physicians, particularly those who derive much of their income from office visits.   


It has been 20 years since the 1997 E&M guidelines were promulgated.  They were confusing to most physicians then and remain confusing today.  One study from the Journal of Family Practice showed that physicians are accurate in their E&M coding only 55 percent of the time, yet Mitchell King, MD provided a fascinating follow-up investigation in the Archives of Internal Medicine that showed certified coding specialists agree on what the correct E&M code should be just 57 percent of the time!  It calls into question how the afore-cited 55 percentwas derived. 

Second, the guidelines have not been modified or clarified as healthcare has evolved.  EHR usage by office-based physicians was well below twenty percent in '97 - a 20 percent threshold was not reached until '04 and surpasses 80 percent today.  And all of us have seen what happens in an EHR world when physicians are documenting to oblique coding standards rather than documenting their care and care plan. The pearls that drive care and care coordination are hidden in an oyster bed of cut-and-paste and click-and-count documentation that serves no one. 

Medicare considers it fraud when a physician over-codes.  Medicare's Recovery Audit Contractors (RACs), charged with finding said fraud in the healthcare system and being paid a commission of between 9 and 12 percent for finding fraud, have attacked physician overuse of high level E&M codes and pulled back millions when the documentation does not support the code.  Other payers have followed suit, of course.  

Physicians must bill patient visits using a 20-year old set of guidelines that were murky as hell back then and remain so.  Physicians may be penalized for selecting the wrong code, and doing so is considered fraud…even though coding gurus disagree on what the right code really is!  You can't make this stuff up.


CMS has indicated its intention to study and revise E&M coding in the next few years.  They want to de-emphasize the detailed history and physical exam and put the focus on time, medical decision-making, and coordinated care.  I would be naïve to say change is coming out of the purity of someone's heart.  The national organizations that should have pushed for change in the past 20 years have not done so. 

The impetus is money.  Medicare data shows that level 4 and 5 E&M services were billed 25 percent of the time in 2001.  This number has increased to 40 percent by 2010.  Vague E&M guidelines, combined with the way physicians document in EHRs to try and meet these guidelines, have resulted in higher levels of E&M coding. 

Here's an example of the money at play.  Family medicine physicians coded a 99213 or a 99214 a mere 35,000,000 times in 2015, according to CMS data.  There's a $34.45 difference between Medicare reimbursements for these two codes where I live.  And $34.45 times 35 million visits is $1,200,000,000 and change.  Now think about the dollars at stake when we look at all specialties and all E&M codes.  I believe Medicare is seeking to simplify E&M coding to reverse the EHR-driven shift to higher coding. 

For now, code as best you can.  Make sure you do not use a single established patient or new patient code too much, as doing so puts you at greater risk for audit.  Keep clicking away to document, even if all of your clicks aren't moving the needle on care or care coordination.

Reach out to your national and state professional and specialty societies.  Make sure they have a seat at the table as the E&M guidelines are overhauled.  We must make sure income is protected during this process.  Change is coming and is overdue…let's make sure we're at the table and not on the menu.


Lucien W. Roberts, III, MHA, FACMPE, is administrator of Gastrointestinal Specialists, Inc., a 25-provider practice in Central Virginia. For the past twenty years, he has worked in and consulted with physician practices in areas such as compliance, physician compensation, negotiations, strategic planning, and billing/collections. He may be reached at muletick@gmail.com.

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