Evaluation and Management Documentation, Billing, and Coding

Abstract

Correct evaluation and management (E & M) coding and billing is a core system-based practice competency. Yet, most residents feel unprepared when they have to start documenting and billing on their own. Poor understanding of E & M coding leads to defensive billing, costing practices, and academic institutions untold amounts of money. It also leads to physicians overdocumenting in hopes to justify a higher charge. Worst-case scenario, inappropriate billing can lead to criminal or civil penalty. Unfortunately, poor billing practices often start with staff doctor educators who themselves do not properly understand the billing system. This chapter informs the reader that current E & M coding is straightforward. Written in a tongue and cheek style, the author hopes to keep the reader’s attention and demonstrate that understanding of the current billing system has many unexpected benefits in addition to increased practice revenue. Trainee competency in E & M documentation, billing, and coding should be a cornerstone of all surgical residency and fellowship training programs.