Physician Documentation and Code Assignment

Physician Documentation and Code Assignment

Setting the Foundation for a Successful 2024

It’s no secret that the Evaluation and Management (E/M) guidelines have an impact on reimbursement. Assigning the appropriate E/M code is a must in any clinic setting. It sets the stage for financial stability. As more physicians join large practices, implement electronic health records (EHR), or become part of facility ownership, avoiding loss of revenue becomes more critical in today’s complex healthcare environment. In 2020, the Centers for Medicare and Medicaid Services (CMS) revised code descriptors and documentation standards to alleviate administrative burdens. The 2023 Current Procedural Terminology (CPT) code set changes were aimed at further decreasing the administrative burden associated with code assignment and billing. So, in 2024, what are the barriers?

The Barriers

Despite ongoing efforts, it has become clear that physicians are often caught in a cycle of poor documentation. After all, they went to school to be physicians, not writers. Physicians focus solely on procedures and procedure documentation; they don’t see the value of ICD-10-CM diagnosis coding. The fact is ICD-10-CM code assignment is imperative for today’s claim-based reimbursement. Physicians can only demonstrate how sick their patients are via structured coded data, which depends on accurate documentation. It’s time to think outside the drop-down box and think about telling the patient’s story. By accurately telling the patient’s story, a physician can ensure that all chronic diseases, social determinants of health, and other factors affecting the patient are acknowledged on a claim.

Some physicians may believe that the basis for a patient visit rests solely on the highest element of medical decision-making (MDM). Physician documentation habits are often the result of who taught them. They have become so accustomed to working in a certain way, or documenting a certain way, that it has become ingrained in them and hard to change. Are they copying and pasting information from previous encounters, but missing that second step of documentingwhy it is important on the current visit? It is important to remember that Medical Decision Making (MDM) is comprised of three elements; the number and complexity of the problem, the amount or complexity of data to be reviewed, and the risk of complications. Every element should be present in their documentation.

Physicians communicate in clinical language, but coders work in the language of code assignment. Those two areas do not always align. There is so much riding on the alignment of quality measures, risk adjustment, and payer contracts to leave it off the list. While coded data continues to be the structured data of choice in healthcare, it was designed to be used as a mortality index, causing code sets to evolve. It was never really designed for reimbursement, but here we are. In addition, the impact of social determinants of health on patient care continues to gain momentum. Physicians may struggle with capturing these types of diagnoses as well as the patient’s long-term prognosis. 

There is Hope

Several options are available to physicians to mitigate E/M code assignment. A comprehensive training program to elevate current staff into new roles such as CDI or Coding can help bridge the gap in documentation. This solution offers the most flexibility. Choosing a current staff member to elevate gives a “known feeling” of who they partner with. Investing in their staff can go a long way. Another solution is to start, or enhance, a clinical documentation integrity (CDI) program. Allowing for at-the-elbow support of physicians with CDI staff is a proactive approach to bridging gaps in documentation.

Recent updates to E/M documentation and coding guidelines continue to have a financial impact on physicians. Every physician wants to be appropriately reimbursed for the services they offer. CSI can provide subject matter experts to compliment your workflow practices and assist in ensuring accurate documentation and coding. Don’t start 2024 unprepared, reach out to us today at! 

Picture of Lou Annn Weidmann

Lou Annn Weidmann

Director of Provider Coding Operations


Work hard. Play Hard. 

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