425Take a moment to think about your current billing skills. Are you the master who
should have written this chapter, or are you a neophyte? Where does your billing
stack up compared to your peers? What are your average RVUs per encounter?
These questions led me to audit our entire surgery department and man were there
disparities. Crazy disparities (I won’t even mention that one of our most lucrative
divisions charged zero consults over an entire year – their biller was under the mis-
conception that consults no longer existed – true for Medicare patients not true for
most other payers – WOOPS!!!!). If you are an outlier from the group on billing, you
can be rest assured that CMS who sees the same aggregate data will look closer. A
great place to start your journey toward billing excellence is having your office
administrator run the numbers and give you a breakdown of your personal billing
and how you compare to your peers.
Billing Mechanics
I hope I have convinced you that E & M coding is very important. Surgeons often
underestimate the importance of E & M billing since they think they earn all of their
revenue in the operating theater. After examining an entire surgical department, I
discovered E & M RVUs made up between 20% and 45% of total RVUs (and this is
with poor billing). Remember that there is rarely a dispute to an E3 charge, whereas
complex surgical charges are often questioned and require appeals, etc. The good
news is that billing is totally learnable.
All E & M notes rest on the foundation of the three billing pillars (Fig. 23.1):
history, physical exam, and medical decision-making. A new patient visit (or con-
sult visit) requires all three components. An established patient visit requires only
two of the three!!! Thus, a follow-up established visit can be devoid of a history or
physical exam (you pick which one) entirely. This is because there will always be
medical decision-making. In 9 years of giving talks on billing and asking the audi-
ence what the fundamental difference is between an established and new patient,
only one has answered correctly.
Before I launch into billing mechanics, I want to mention that the minimums I
mention are for billing purposes only.
Minimum Billing Requirements ≠ Best Patient Care Documentation
I always will document more than the billing requirements when I feel it reveals
important medical information and leads to better patient care. But I do not list
anything more than necessary if it doesn’t add to the note. Have you seen the notes
that EHRs produce these days?
Pillar 1: History (Fig. 23.2)
The term history often conjures an image of the six-page H and P one performed
on their first internal medicine rotation. This type of note and notes for billing effi-
ciently couldn’t be more different.
23 Evaluation and Management Documentation, Billing, and Coding