W8D1 Evaluation and MGT: Evaluation and Management Key Components
Medical decision-making is a crucial component in deciding the level of E/M code. This part involves scrutinizing the doctor’s diagnostic abilities, including how he chose treatment. The aspects of medical decision-making are the mind-numbing difficulty level of deciding one diagnosis from several others and the confusion resulting from the fact that a large amount of information must be reviewed and processed quickly.
Sometimes, medical decision-making plays a pivotal role in cognitive workforce efficiency, as measured by the cognitive labor expended by the provider. The greater the elevation, the more complex, and other activities require more attention with profound analysis and clinical judgments of the service provider. Patient management demands a precision health code, guaranteeing correct remuneration according to the physician’s work complexity. There are four levels of medical decision-making: simple, average, exceedingly high, and high. Straightforward cases involve minimal diagnosis or treatment options, data review, and risk. Low complexity factors in limited diagnoses, data review, and minimal risk. Moderate complexity considers multiple possible diagnoses, moderate data review, and moderate risk. High complexity captures an extensive diagnosis or treatment option list, extensive data review, and a high risk of morbidity.
To determine the overall medical decision-making level, a coder would assess the extent of each contributory element (diagnosis/management options, data review, risk) and select the highest level met by at least two of the three elements. For example, if a case meets at least two elements for moderate complexity, that would be the overall medical decision-making level. This key component is crucial in selecting the final E/M service code.
W8D2 Services: Services in the Evaluation and Management Section
The CPT code set E/M section classifies many types and subtypes encompassing a broad spectrum of healthcare provider activities. One of the significant sub-categories is the Consultations, which can be interpreted as a set of diagnostic codes in which a provider requests another provider’s opinion or advice on the evaluation and treatment process for a particular case.
Some example consultation codes and descriptions include:
99241 – Post talk for a new or designated patient requires these three critical elements: A hardship account, A problem-first research, and A troubleshooting approach to care, all of which reduce physician cognitive burdens.
99252 – Inpatient consultation for a new or established patient needs these three critical elements: Wider horizons and improved scope of history exams; broader horizons and better range of problem-focused exams; and detailed medical decision-making.
99255 – Inpatient talk for a refreshed or designated patient needs these three essential parts: A complete history list and physical and medical decision-making, which has proved challenging. The consultation codes would be applied when the provider seeks advice or opinion from another physician to aid in evaluating or treating the patient’s condition (Campbell & Giadresco, 2020). The congratulatory function of that service guarantees that patients have a beneficial team ranging from general practitioners to specialists in the illness. Consultation codes tend to have higher relative value units and reimbursement than codes for typical office visits or inpatient care by a single provider (Grannis, 2023). This reflects the additional physician work and cognitive effort to provide an expert opinion after an in-depth evaluation.
W8D3 Coverage: Veterans and Military Coverage
The provision of healthcare to military vets through the Veteran Health Administration, being the main objective of discourse, has been an issue of concern and discussion for a long time. As it seems from the reports analyzed and data provided, the VA system encounters some daunting challenges in ensuring the health care services are of high quality and consistent across facilities.
A 2022 Veterans of Foreign Wars Institute evaluation gave the VA healthcare system an average grade of C, highlighting the constant issues of human resources shortage, aged infrastructure and restricted or long waiting periods in some places. Besides that, the report brought about essential advancements in services like mental health and community care choices. Similarly, a 2020 study published in JAMA Network Open found veterans receiving outpatient care through VA facilities experienced slightly lower rates of mortality and consistent or better quality compared to non-VA care for many outpatient measures. However, the study also identified opportunities to improve care transitions and address geographic variations in quality.
Before learning more, my perception was that VA healthcare suffered from systemic problems and lagged significantly behind standards at top private healthcare systems. However, the picture appears more nuanced based on recent objective assessments. While deficiencies exist, the VA system has made strides and, in some cases, delivers outcomes comparable to or favoring VA facilities. For veterans who require urgent care outside of VA settings, my findings reinforce the importance of carefully reviewing quality data for those non-VA providers to ensure optimal care coordination and management of complex conditions or follow-up needs. An open discussion with veterans about their experiences and preferences regarding VA versus non-VA care will also be valuable.
QW8D1 Auditing: Auditing Practices
Auditing is a crucial element of the medical coding and billing industry that entails testing the accuracy of the submitted data and compliance with the rules. There are pros and cons to the different types of auditing processes:
Prospective audits review claims before they are submitted for payment. The pros include proactively identifying and correcting coding errors to prevent denials or improper payments (Mills, 2023). This approach can save significant time and resources compared to recouping overpayments later. A con is that prospective audits require staffing resources to complete reviews promptly before billing cycles. Retrospective audits examine claims post-payment to identify any coding, billing, or documentation issues that led to over or underpayments after the fact. An advantage is not impacting billing workflows with pre-payment reviews. However, recovering overpayments can be challenging, and retrospective audits may miss opportunities for real-time provider education.
It is considered best practice for medical practices to perform routine internal audits, whether prospective or retrospective. Internal audits allow proactive monitoring and improvement of coding accuracy. They facilitate ongoing provider training and feedback loops. Well-designed internal audit programs can reduce costly external audits and penalties by third-party payers. External audits by payers or oversight entities aim to identify billing vulnerabilities and abuse across a provider’s claims history. They serve as an accountability mechanism but can consume significant resources to comply with information requests during the audit process (Mills, 2023); as a coding professional, auditing skills would be highly advantageous. Internal audit experience would make me a stronger candidate for coding roles by demonstrating expertise beyond applying codes to documentation. An auditing background promotes process improvement, supports compliance efforts, and develops skills in analyzing coding patterns, communication, and providing feedback to providers.
W8D2 Future: Future Career Path and Goals
Within my job search in the medical coding and billing field, I checked out the job openings at Indeed for medical coders’ roles, such as “Certified Medical Coder,” “Medical Coding Specialist,” and “Medical Coder and Biller.”
One appealing opportunity was a Coding Specialist role with a regional healthcare system in Atlanta. The requirements included:
AAPC CPC or CCS certification
1-3 years of experience in ambulatory coding for Evaluation/Management services
Proficiency in medical terminology and anatomy/physiology
Knowledge of CPT, ICD-10-CM, and HCPCS Level II code sets
Strong attention to detail and analytical skills
To tailor my resume, I would highlight my recent completion of the medical coding program with a 4.0 GPA, my CPC certification, coursework covering all required code sets, and examples of coding cases from class that demonstrated EM coding for different specialties (Grannis, 2023). Another exciting role was a Remote Inpatient Coder with a national coding services company. This position involved reviewing inpatient admission records to assign ICD, CPT, and DRG codes accurately. Requirements included:
RHIA, RHIT, CCS, or CPC certification
3+ years of acute care facility coding experience
Knowledge of MS-DRGs, ICD-10-CM/PCS
Excellent critical thinking and auditing skills
Experience coding from electronic health records
My resume would emphasize my coding program focus on ICD-10-CM/PCS and DRG coding, knowledge of EHR systems from class cases, and the critical thinking exercises developed through practice coding inpatient operative reports and evaluating coding scenarios.
Effective job search techniques included using coding credential acronyms like “CPC” or “CCS” and including geographic filters to narrow results. When describing skills, I would highlight my coding certification, experience with EHR systems and encoders through the program, official coding guidelines, and ability to apply coding conventions through coding cases across specialties.
For the last one, find work-from-home jobs in Georgia
One remote coding job opportunity based in Georgia was for an Outpatient Coder with a virtual coding services company:
Responsibilities: Review and code outpatient physician encounters, procedures, and ancillary services
Requirements: CPC or CCS certification, experience coding from electronic documentation, proficiency with CPT, ICD-10-CM, and HCPCS Level II codes
Location: Work from home position but must reside in Georgia
Skills Highlighted: Experience
References
Campbell, S., & Giadresco, K. (2020). Computer-assisted clinical coding: A narrative review of the literature on its benefits, limitations, implementation and impact on clinical coding professionals. Health Information Management Journal, 49(1), 5–18. https://doi.org/10.1177/1833358319851305
Grannis, M. (2023). Medical Billing & Coding Guide For Beginners: Guide to a Successful Career as a Medical Biller & Coder. Croatia: Martha Grannis.
Mills, S. L. (2023). Medical Coding: A Guide to Success as A Coding Professional. (n.p.): Amazon Digital Services LLC – Kdp.
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