Outpatient CDI Program Focus: Evaluation and Management (E&M) Services

Implementing an effective strategy begins with an assessment of E&M claims data by specialty.

Evaluation and management (E&M) services are cognitive services of physicians and advanced practice providers (APPs) for the diagnosis and treatment of an illness or injury. E&M services comprise 40 percent of all allowed charges under the Medicare Physician Fee Schedule each year. 

Office visits for new and established patients comprised 45 percent of all E&M volume for the 2020 calendar year! The next-highest category or setting was hospital inpatient services, which make up 22 percent of the volume, followed by home services at 7 percent.

Patient care in the home as risen significantly in use; in 2010, it was less than 1 percent of the E&M volume. In January of this year, the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services (CMS) collaborated and revised the documentation requirements for office visits; this was the first change to the E&M guidelines in 25 years!  

This leads me to this question: can an outpatient CDI program focused on E&M services to ensure accurate patient acuity and proper payment be a priority focus? I say yes! Others think so too: the Association of Clinical Documentation Integrity Specialists (ACDIS) September 2021 industry overview survey reported that 7 percent of CDI programs with outpatient efforts were focused on E&M services. 

These services, like all services, must have documentation in the medical record to support the care delivered and the level of service billed. Payment for E&M services has historically been a review focus of CMS, Medicare Administrative Contractors (MACs), the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), and commercial payers, all with a concern of improper payment. These reviews focus on medical necessity and documentation and coding that result in inaccurate payments. Additionally, physicians and APPs often are required to do their own billing, with little to no validation prior to claims submission. 

Implementing an effective strategy begins with an assessment of E&M claims data by specialty; create a bell curve of the data to view the distribution of the E&M levels of service within the individual categories. I suggest you begin with the top three E&M categories noted above: office, inpatient and home visits. Then, compare the data with national benchmarks to see where potential gaps exists. If your volume of E&M services is high, this analysis, combined with a chart review, will help you determine where to begin your E&M efforts. You want to focus where you see risk in over-coded levels of service, and opportunity in under-coded levels of service. The CDI specialist, of course, must have expert knowledge of E&M level selection guidelines to be able to effectively communicate and educate physicians and APPs on the category and level selection criteria. 

Meet with your providers and educate them on the findings of record reviews, and demonstrate to them where their documentation and/or level selection resulted in inaccurate claims and under- or over-reporting patient acuity. Continue to monitor and provide feedback to ensure that your efforts are successful.

Track and share the progress against the initial baseline bell curves to show return on investment and program success. 

Association of Clinical Documentation Integrity Specialists (ACDIS) 2021 industry overview survey available at https://acdis.org/cdi-week-type/industry-survey