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Evaluation and management coding is an important topic in the U.S. healthcare environment because it relates to billing processes in healthcare institutions. According to Buppert (2018), Evaluation & Management services are the most widespread CPT codes in primary care and specialty practices. E&M coding involves billing for healthcare services based on the “provider’s cognitive services, such as office or clinic visits, consultations, preventive medical examinations, and critical care services” (p. 320). These codes also take into account the complexity and extent of procedures, thus giving a fair option for healthcare billing (Buppert, 2018). E&M services coding relies on standards and guidelines provided by the Center for Medicare and Medicaid Services (CMS). The study by Young, Bayles, Hill, Kumar, and Burge (2014) discusses these guidelines and their effect on healthcare practitioners.
First of all, researchers note that the goal behind CMS guidelines on E&M services was to reduce healthcare fraud (Young et al., 2014). Since the introduction of guidelines in the 1990s, they were reviewed once, despite calls for reform from care providers. Young et al. (2014) state that healthcare professionals complained about CMS guidelines due to their increased complexity and extended bureaucracy.
Secondly, the authors sought to address these concerns by studying the attitudes of family physicians to E&M services coding documentation. The researchers used a qualitative study design to collect the opinions of 32 family physicians in various types of practices. The results were analyzed using an immersion-crystallization approach, which allowed uncovering common themes and attitudes. On the whole, the study found that the participants perceived coding rules and fees for procedures and services to be reasonable (Young et al., 2014). Nevertheless, they complained about the complexity and the confusing nature of E&M documentation. Some of the participants also noted that the new E&M rules instilled a fear of false fraud allegations and took too much time from their consultations with patients (Young et al., 2014). The authors conclude that improvements are required to make E&M coding and documentation process easier and more transparent. The key ethical implication of the article is the improved quality of practice in the U.S. since care providers would be able to focus more on their patients. From the legal viewpoint, the suggestions stipulated in the article can help to reduce fraudulent billing.
The author’s concerns with E&M coding are supported by other healthcare professionals, scholars, and practitioners. Marting (2018) notes that there are certain limits in E&M coding rules that affect care providers’ ability to fill in the documentation correctly. For instance, the system does not allow selecting a visit based on time except when the duration of face-to-face time with the patient is documented, and at least 50% of the visit is spent on counseling or care coordination (Marting, 2018). Indeed, such rules appear to be overly complex and excessive, and they have a poor impact on care providers’ ability to focus on their patients.
Impact on Nursing Practice
Recently, changes to the E&M coding rules were suggested, which could address these issues, making coding and reimbursement more objective and simple (Roberts, 2018). However, until these changes are signed into force, care providers will be affected by the weaknesses of CMS rules regarding E&M coding. The effect on nurse practitioners working independently is the increased workload due to complex billing documentation, as well as the threat of reduced reimbursement due to the subjectivity of the current E&M coding. For nurse practitioners working in collaborative practice, shared or split billing would be the key issue, as some E&M services may be billed under the physician’s or other care provider’s NPI number, which creates additional complications (WOCN Society National Public Policy Committee, 2012). Overall, developments in E&M documentation and coding rules would benefit all care providers, including nurse practitioners.
Buppert, C. (2018). Nurse practitioner’s business practice and legal guide (6th ed.). Burlington, MA: Jones & Bartlett Learning.
Roberts L. W. III. (2018). Thoughts on CMS’s dramatic proposal for E/M guidelines. Web.
WOCN Society National Public Policy Committee. (2012). Reimbursement of Advanced Practice Registered Nurse Services: A fact sheet. Journal of Wound, Ostomy, and Continence Nursing, 39(2), 7-16.
Young, R. A., Bayles, B., Hill, J. H., Kumar, K. A., & Burge, S. (2014). Family physicians’ opinions on the primary care documentation, coding, and billing system. Family Medicine, 46(5), 378-84.