Introducing Avo’s E/M Documentation Review

Whether it’s a clinician selecting the CPT E/M billing level based on their best understanding of the coding system, or a coder picking an E/M level based on incomplete documentation, E/M coding can be difficult to get right. Undercoding leaves reimbursement on the table for the complexity of care delivered. Overcoding creates audit and compliance exposure for clinicians and hospitals. For many hospitals, inaccuracies in E/M coding amounts to sizable revenue leakage: per Medical Economics, a review of 60k audits of physician billing records found that 37% of records were undercoded or underdocumented, equaling approximately $64k in missed or at-risk revenue per physician.

Introducing E/M Documentation Review

Avo’s E/M Documentation Review works alongside AI Scribe at the point of care to identify opportunities to improve E/M coding accuracy, surfacing the evidence-based note additions needed to support the most appropriate level.

In practice, after finishing an AI Scribe recording, clinicians use E/M Documentation Review to analyze the note at the end of a visit. The tool surfaces any gaps and proposes specific additions to the note, that may support a higher and more appropriate E/M billing level. Note that E/M Documentation Review builds the right clinical documentation to support the most accurate billing level, without clinician lift and within the workflow. The clinician can then accept, edit, or dismiss the recommendation. Nothing gets added to a chart without clinician review.

For coding and compliance teams, the effect shows up downstream: fewer charts held for clarification, fewer billing corrections after submission, and notes that support the level billed because the documentation was accurate at the point of capture. E/M Documentation Review never suggests a level beyond what the evidence supports, so every recommendation is both compliant and audit-ready. 

Improving note quality and reimbursement at two health systems

At Granite County Medical Center, this approach took Level 3 billing accuracy from 0% to roughly 80%, cut billing corrections by 87%, shortened the billing cycle from 9 days to 5, and lifted reimbursement 16%. “Avo helps the billing department because they’re not having to dig through our notes,” said Jessica Martin, CMIO at Granite County Medical Center. “It's almost to the point where we don't necessarily need to use it on every single encounter. It's shown me enough about my own notes to help me better categorize levels.”

A vascular surgeon at Berkshire Medical Center, Dr. Alexander Chao, noted that E/M Documentation Review significantly improved the quality of his notes while giving him his time back. After using AI Scribe with E/M Documentation Review, he was able to increase clinic appointments by 20%. “That just would not have been possible without Avo. It was a total lifesaver,” Dr. Chao said. He also mentioned that coders noticed that he was able to code at a higher level, and appropriately so. “[My coder] said that [my notes] look great,” he said. “That gave me even more confidence.”

E/M Documentation Review is available now for hospitals and health systems. Visit avomd.io to learn more or request a demo.