E/M codes are among the major categories of codes that are frequently examined by third-party insurance auditors. Medicare auditors recently have seen many cases in which documentation guidelines are not followed adequately to support a consultation code.
The key reason the documentation is scrutinized is because the reimbursements for consultations are higher than the reimbursement levels for office visits of similar documentation levels. In most instances, if the guidelines were not accurately followed, the consultation was either downcoded or denied. In either case, money is taken back from the practice or the physician. To ensure that the documentation matches the coding, consider the following guidelines.