Symposium spotlight: She wrote the book on E/M coding and documentation

Editor’s note: Karen Newhouser, RN, BSN, CCM, CCDS, CCDS-O, CCS, CDIP, will present “Let’s Talk About Evolution and Management: What Do We Need to Know?” on Day 2 of the ACDIS Symposium: Outpatient CDI, which takes place November 14-15 at the Hyatt Regency in Austin, Texas. Newhouser is the clinical documentation integrity content manager at AMN Healthcare Revenue Cycle Solutions (RCS) in Tampa, Florida.

Q: You literally wrote the book on evaluation and management (E/M) coding. Why do you think this is such an important topic for CDI professionals to know about?

A: A quick and easy definition of E/M is that it determines how the provider is reimbursed for their professional services; however, that’s the end result. How one attains that result is much more important. It begins as it should, with the patient, and ensuring the documentation of the medical decision making during the encounter (whether inpatient or outpatient) is complete and precise. Put “patient,” “documentation,” and “medical decision making” together and you have described the elements that lie squarely in the wheelhouse of the CDI professional.

Q: What’s the biggest misconception about E/M coding and documentation requirements? Why do you think people misunderstand it?

A: The biggest misconception is that they’re complicated. I was first educated on E/M in 2011 when I obtained my Medical Office Coding and Billing Certificate, and I was truly lost! Once I stumbled upon the “encounter flow” method of E/M a few years ago, it finally made sense and I’ve been teaching that method of E/M ever since.

Q: How can you leverage E/M information for physician education?

A: The simple answer is to work from their mindset and speak their language. Their mindset is that of all clinicians—focusing on the patient and delivering quality care. I feel if we begin to use terms such as “medical decision making,” “medical necessity,” and “management/addressing” while focusing on the patient in all healthcare settings when speaking with the provider, that will go far in getting us all on the same page.

Q: Is E/M solely an outpatient concern? What do inpatient CDI professionals need to know about this topic?

A: Because E/M codes are based on professional services, the provider is billing for their professional services for inpatients as well. One of the biggest misunderstandings is that a provider can’t/shouldn’t document uncertain diagnoses in the outpatient setting. While it is true that a diagnosis documented as uncertain cannot be reported (i.e., coded), the provider must be encouraged to document all uncertain diagnoses to support their medical decision making. However, because the provider has historically focused on documenting only diagnoses with certainty, this presents a small challenge in the inpatient setting as they are often hesitant to document uncertain diagnoses. Due to the specific rules for the outpatient and inpatient settings, the provider should be encouraged to document the certain condition(s) (often signs and symptoms) and link them to the uncertain condition(s). An example would be “cough, shortness of breath due to possible pneumonia.” This would provide a more complete picture of the patient in addition to satisfying both the inpatient and outpatient guidelines.

Q: What’s one thing attendees can expect from your session at the Symposium?

A: Attendees can expect a practical, common sense CDI approach to E/M that is in alignment with the projected changes in calendar year 2021.

Q: If you could live in any TV show or movie, what would it be and why?

A: I think it would be fun to live in Seinfeld. The emphasis on relationships while tackling real life situations and injecting humor without changing the message is enlightening. We all need relationships, truth, and humor in our lives.