The Importance of Proper Documentation in E&M and Procedural Coding
In this edition of The JARALL Quarterly, JARALL founder and CEO Dr. Alan Bass tackles one of the questions he still hears most often — even years after the 2021 overhaul — how proper documentation drives correct E&M and procedural coding. Client Services Manager Eric Childress moderates a live Q&A at the end, with real podiatric scenarios pulled straight from attendees.
What You'll Learn
The Post-2021 E&M Framework: how coding moved away from the old review-of-systems checklist to a model built on Medical Decision Making (MDM) or time, and why those body-system exams are no longer required
The Three Columns of MDM: number and complexity of problems addressed, amount and complexity of data reviewed or analyzed, and risk of complications — and why you must satisfy two of the three to bill a given level
Coding by Time: what counts toward total time on the date of service (preparing, reviewing records, care coordination, documentation — your time only, that day only), when to use time instead of MDM, and how auditors scrutinize time-based billing
Prolonged Services (99417): when a level-5 visit qualifies and how additional units are added once you exceed the 75-minute (new) or 55-minute (established) thresholds
The Buzzwords Auditors Look For: the specific language ("stable, chronic," "acute, uncomplicated," "undiagnosed new problem with uncertain prognosis," "threat to life or bodily function") that maps each problem to a level of coding
Avoiding "Notebook" Documentation: why four pages of padding doesn't raise your level, and how succinct, relevant notes hold up better in an audit than over-documented ones
Which Diagnoses Belong on the Claim: why diagnosis codes unrelated to the day's treatment should stay out of the E&M coding even if they're worth noting in the history
E&M Plus a Procedure on the Same Day: the "two freestanding notes" test for whether you can bill both, why every procedure already has an E&M element built in, and why the procedure itself is never the "management" portion of the encounter
Documentation That Passes an Audit: the difference between "discussed all options" and listing the specific options, risks, and complications, and why you can write that a patient "appears to understand" but never that they "understood"
Why This Matters
Proper documentation is the difference between getting paid for the work you do and losing revenue to denials and downcoding. The 2021 guidelines were meant to make documentation easier — but EHR templates, outdated habits, and second-hand advice still push physicians to over-document the wrong things while under-documenting what actually supports the code. Whether it's an ingrown toenail, a neuroma, plantar fasciitis, or an at-risk diabetic foot, the level you can bill comes down to the words in your note — and whether your evaluation, your plan of care, and your procedure each stand on their own.
Watch the full webinar above for Dr. Bass's walkthrough of the E&M table, podiatric examples for every level of MDM, sample documentation that does (and doesn't) survive an audit, and a live Q&A covering same-day procedures, new-patient encounters, at-risk foot care, and more.