Evaluation and management services: documentation and coding

Evaluation and management coding is one of the most important aspects of billing. Proper coding helps with timely billing and collection. One of the most common errors in medical billing is improper coding for the Evaluation and Management (E&M) services. There are not too many studies published on this subject, and it is hard to find published data; however, this information is readily available on the Center for Medicare and Medicaid Services. Being familiar with the CPT book and using it properly will avoid miscoding and help prevent errors in billing. Documenting the essential sections and billing for a patient encounter requires familiarity with the E&M codes. It is not uncommon to over or under code a certain encounter. Although under coding is more commonly seen (more than required documentation and/or services), over coding is what leads to fraudulent billing and subsequent liabilities. This article will explain some of these intricacies and hopefully help a practitioner follow proper guidelines to avoid any improper billing.