After my audio program last week, there is always a persistent question: “If I choose a code first before I document, coudn’t that be dangerous?”
Well, it’s a polite question that is really saying…”Isn’t this fraud?”
It’s not, and here’s why.
The three key components of an E/M code are:
- History
- Physical
- Medical Decision Making, (MDM)
Two out of the three key components will qualify for an E/M code.
 So…. technically, you could have a patient present with a hangnail. Do a huge history, and a huge physical exam, and bill for a level 5 office visit. Yes?
Well, you can. But if a pattern of this type of billing occurs, you should expect a visit from an auditor and charges of fraudulent billing will follow.
Here’s the difference, (a difference I’ve been speaking about for years now, but only in the past year has the OIG decided to look at the “medical necessity” behind the code as a more differentiating feature).
When audiences hear me present my Risk Based Coding TM algorithm, they say “so you pick the code first, then document to justify the code.”
Absolutely not.
What my system does is choose a compliance correct E/M code based on MEDICAL DECISION MAKING. In otherwords, the E/M code is not based on a random, or intentional, choice of a HIGH, or otherwise, E/M code. It’s based on the Medical Decision Making element of the three key components. A “medical necessity” driven MDM. So in my Risk Based Coding TM documentation system, the E/M code is JUSTIFIED by by Medical Decision Making. The E/M code is then SUPPORTED by the necessary AMA/HCFA/CMS documentation requirements.
Otherwise, one could commit fraud by selecting a high E/M code and JUSTIFYING it with documentation.
That’s a set-up for disaster.
When you choose an E/M code, let the medical necessity, driven by Risk, and Medical Decision Making, be the guiding force in choosing the appropriate level of E/M service.
If you’d like to know more about my Risk Based Coding TM algorithm, visit here.
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