E & M Coding: One Physician’s Decision to Learn Everything

How much do you know about coding and clinical documentation? 

If you’re a physician, you probably don’t feel like you know enough.  At the same time, you probably know more than you ever wanted to know.

Dr. Andrew Worthington felt that way more than 8 years ago. As a practicing neurologist, he learned about diagnosing a patient’s illness in medical school. He went to school for 4 years to learn these medical decision making (MDM) skills and then spent practical time applying the skill set in residency and fellowship. As a doctor, Andrew was also responsible for translating that MDM into a diagnostic code that accurately reflected the services he provided as a neurologist so the code could be interpreted by a non-medical person for processing within the healthcare system. 

Dr. Worthington had been in practice for a little more than 12 years when he became overly frustrated by the fact that he had spent over a decade in school and training to become a neurologist but he had gotten very little training or continuing education in this documentation process, even though it was a vital part of his day-to-day responsibilities and expectations of the job. Correct use of Evaluation and Management (E&M) codes determined how he got paid for the work he did and provided the proof of his level of service for a patient. 

With his partners’ blessing, he used a data-driven method to track the way the practice used clinical documentation. What he found astonished him and his partners.

The practice was losing thousands of dollars of year due to undercoding. Andrew realized his colleagues were being conservative about their documentation because of their lack of training. Most of his colleagues weren’t translating their MDM into the codes that properly described all the work they had done for their patients. Because of this, they were also putting themselves at risk for a compliance audit.  

Although he enjoyed the practice of neurology, Dr. Worthington devoted himself full-time to learning about E&M coding for a year.  He developed a program to train his colleagues in neurology on how to be accurate and complete in their clinical documentation. His program was so successful that he created a live E&M coding and documentation training program that can be customized by specialty and practice size that is now offered throughout the country.  

“I draw on my medical training and clinical experience to instruct physicians from a practitioner’s point of view. It is gratifying to be able to teach other physicians because we speak the same language. 

“My goal in this is to help my colleagues understand how to translate the things they learn in medical school about patient complexity and MDM into the correct level of coding for non-physicians to interpret and understand. I want to keep my colleagues out of trouble and help them earn the reimbursement they deserve. I love the practice of neurology but this allows me to give back to others in the healthcare system that help patients just as much as I do – maybe more”.

For a good resource on Physician Documentation, you can visit Dr. Worthington’s website at http://www.codebluecoding.com where you will find more information and links to free articles on coding and compliance.