Though medical coders are the people responsible for sifting through patient documentation and choosing the correct codes for a diagnosis, they are only one side of the coin. On the other half lies clinical staff, the doctors, nurses, therapists, and other medical professionals responsible for treating patients and assigning them diagnoses in the first place. Because of the dual nature of this equation, many believe that the specifics of coding, especially Evaluation & Management, are the sole responsibility of the coders, but in truth, it is the duty of both sides to strive for the best possible documentation.

Clinical staff members are the ones dealing directly with patients, so it’s only natural that they have a deep understanding of a patient’s condition. However, they should always review their notes to ensure that they did not accidentally take a piece of patient info for granted. For example, diabetes is a commonly miscoded E&M issue, as some physicians will simply write “diabetes” on a patient’s chart. Under standard conventions, however, the coder must choose a CPT designation that specifies that the diabetes was either without complications or with them, in which case the type and method of control must also be listed. Without this specification, the coder must either take time to send a physician query or make the assumption that the diabetes had no complications, which in turn can result in an incorrect code.

This process, known as “undercoding” or “downcoding,” means that the code will not cover the full diagnosis and will therefore cost the practice the difference. As if that weren’t bad enough, this type of miscoding is also grounds for an audit, meaning that the hospital or clinic may fall under scrutiny even though the insurance company actually saved money. Such discrepancies may sound like rare occurrences, but in reality, the AAPC estimates that as many as one-third of all E&M codes are undercoded or under-documented.

When both a patient’s care and a facility’s professionalism are on the line, it is up to coders and clinical staff alike to work toward a solution. One major step in the right direction is for both sides to learn as much as they can about E&M codes so that the documenting and coding process can remain fluid from the beginning. The more that healthcare employees understand about the other sides of the medical business, the more patients will be able to receive the proper care and billing that they need.