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E & M Coding for Pain Management

Documentation is the most important element, if it is not documented, it did not happen.

Documentation provides evidence of the clinical service provided to the patient.  It is used to communicate to other clinicians, billing and coding, insurance companies and other healthcare entities.

Why it matters:

  • Provide the best patient care
  • Ensure consulting physicians have accurate information
  • Justify level of service and necessity of ancillary services
  • Obtain appropriate reimbursement
  • Protect your practice from audits

New Patient vs. Established patient

  • New patient visits require 3 of the 3 components to be documented
  • Established patient visits require 2 of the 3 components documented

Common mistakes in physical exam documentation:

  • A new patient needs a least 6 bullet points to code a 99202
  • We often down code to a 99201 because 5 or less exam bullets are documented
  • Copied or duplicated notes from prior visits
  • Not reporting negative findings
    • If you examine a body area, mention it even if it is normal.
    • Documentation of benign finding is important as it allows the biller to assign additional diagnosis codes.

Melissa Billman

About the author: Melissa Billman is the billing director for C E Medical Group, a nation-wide medical billing firm that specializes in working with pain management, sport medicine, family practice, and orthopedic surgery. In addition to managing her large team of medical billers and coders, she speaks nationally at various billing and coding conferences. Melissa resides in Salt Lake City, Utah with her husband and two children.