Evaluation & Management Codes Are Failing Us


We believe that the Evaluation and Management (E&M) visit codes are failing in their purpose to report a meaningful summary of the patient evaluation during an office, hospital or other type of visit.

In my opinion, the SOAP note, where providers report the subjective, objective findings and then conclude with the Assessment and Plan of the patient encounter should be abandoned. Providers should revert to reporting the:

  • Chief complaint

  • History of present illness

  • Positive subjective findings

  • Objective positive findings or concerns

  • Then spend time discussing the plan

The Review of System and exam that was done should be placed in a history file for detail review if needed. Determination of the level of care in order that the provider is paid should be based on each specialty creation of medical necessity complexity so the provider can stop guessing what level of care to bill. In the office setting there are four codes to use. The national bell curve reports level III as the code most frequently used. In fact, the level IV and V should be the most frequently code used.

This national bell curve is a reflection of poor reporting and guessing at the code level. In review, the note typically is dictated copy and paste with too much information – so providers only look at the last page of the note to find the information they are looking for. Based on my many years of experience in the billing and coding industry, I believe that the health care system should terminate all the meaningful use programs and spend the next 12 months redefining the provider SOAP note. This would enable the payers to then identify what meaningful outcomes to pay providers for performance incentives.

#EMvisitcodes #SOAPnote #EvaluationManagementCodes #MeaningfulUse

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