E/M office visit coding series: Code the visit just by looking at your assessment and plan

The first post in this series outlined how to code most E/M office visits in just two steps:

1. Use total time if that credits you appropriately for the work you did,
2. Use medical decision making to code the visit based on the level of problems you addressed and medication management.

Now here’s a way to do your documentation that will allow you to quickly determine the visit level for most visits just by looking at a single sentence in your assessment and plan. I call it the Problem/Status/Rx (PSR) format.

Once you’ve described the problem(s) you addressed at the visit, the status (whether the problem is stable or unstable), and your prescription medication management (Rx) in the assessment/plan, you have all the information you need to code most visits. This requires very little text. Here are some examples.

Level 3 examples (one stable chronic Illness + Rx):

• ADHD, doing well, continue amphetamine/dextroamphetamine 20 mg.
• Gout, controlled, uric acid 4, continue allopurinol 300 mg.
• Type 2 DM on insulin, A1C 6.5%, continue current medications.

Level 4 examples (one unstable or two stable chronic conditions + Rx):

• Mixed hyperlipidemia, not to goal, increase atorvastatin to 40 mg.
• Hypothyroidism, controlled, continue current dose of levothyroxine.
  
• Peptic ulcer disease, stable, continue omeprazole.”

Key things to remember:

• When documenting unstable chronic illnesses, it is imperative to use descriptive terms such as “unstable,” “not to goal,” “not improving,” “elevated,” “worsening,” or “uncontrolled.” Failing to do so may result in level 4 work being coded as level 3.
• Be careful how you word an “improving” chronic condition. If it’s improving but still not to goal, make sure to say so. Otherwise, it could be interpreted as now stable rather than unstable, and level 4 work could be downgraded to level 3. This is easier to document for conditions that have a quantitative goal, such as an A1C below 7% for patients with diabetes under age 75. For conditions that don’t have a quantitative goal, such as depression, you can write something like “improved, but still significant.”
• Include “continue current medications” in your documentation to signal that you evaluated a patient’s response to medication and, therefore, should be credited with prescription drug management even if you decided not to change anything. You might think that statements such as “HTN stable” or “diabetes controlled” imply Rx management, but it’s best to spell it out explicitly for coders, insurers, and auditors.

Should you document both total time and MDM?   

When is it helpful to “double up” and add total time to your note? Even if you are confident that you have performed and correctly documented a level 4 office visit using medical decision making, adding a total time of 30-39 minutes for an established patient and 45-59 minutes for a new patient will make your level 4 ironclad. However, if your time spent falls below those ranges, then there’s no benefit to including it in the note. It can only cause confusion, potentially resulting in an auditor, insurance company, or coder giving you credit for a level 3 visit. In my opinion, it’s only worthwhile to “double up” and add time to your documentation if you’re coding based on time or if your visit level based on time coincides with your visit level based on medical decision making.

Coming up next: Take the quiz to test your E/M coding knowledge.

— Keith W. Millette, MD, FAAFP, RPh

Posted on Dec. 12, 2022