Why Your Notes Matter More Than Ever
Payers across the industry are sharpening their focus on Evaluation and Management (E/M) coding, especially for higher-level visits. Increasingly, they’re introducing downcoding programs that automatically reduce payment, leaving the burden of proof on the provider to appeal and submit documentation to support the higher level of visit. The appeals process will tie up revenue and resources.
For providers and organizations, this means one thing: your documentation must stand on its own.
Time-Based Coding Risk
Time-based coding is particularly vulnerable. Many providers rely on time documentation, but simply stating “50 minutes spent with patient” is not enough. Auditors and automated review systems want to see what filled that time and why it was medically relevant.
Good documentation should include:
- Activities performed (record review, patient counseling, coordination of care).
- Clinical relevance of each activity.
- How the complexity warranted the time reported.
Without this level of detail, the visit is at high risk of being automatically downcoded.
More Isn’t Better—Specific Is Better
Documentation should tell the story of the encounter. The volume of words isn’t the issue—it’s the specificity and medical relevance that matter. Clear, well-structured notes not only support coding, but they also protect providers and organizations against downcoding and denials.
Bottom Line: Review your documentation practices now. If your notes don’t fully support the level of service you’re billing, you’re leaving your reimbursement to chance.
Need help evaluating your E/M documentation practices? Contact us to schedule a documentation review and protect your organization from unnecessary downcoding risk.