1. E&M Auditing Clarifying Requirements And Providing Tools For Success
Speaker: Marisa Clauson, CPC

2. Documentation requirements
The first step in understanding medical record documentation is becoming knowledgeable of the Evaluation and Management guidelines by which Physicians and Advanced Practice Professionals must document their services.

3. Medical Necessity
“Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported.” Per Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication , Chapter 12, section

4. General principles The record should be complete and legible.
Each documented encounter should include:
The reason for the encounter, relevant history, physical exam findings and prior diagnostic test results.
The plan of care
Date and legible identify of the provider
If not specifically documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.
Past and present diagnosis should be accessible
Appropriate risk factors should be identified.
The patient’s progress, response to and changes in treatment should be documented.
Please remember…. If you cannot read your providers documentation an outside auditor will not be able to either.
If in an audit situation the record is not legible, they may discount part or all of your E&M service.

5. Cloned Documentation is Inappropriate
Centers for Medicare & Medicaid Services (CMS) contractors have been monitoring supporting documentation of E/M services, and have noticed among EHR users a high volume of records with identical documentation across services. In other words, information from previous encounters is brought forward without updating, which brings into question the validity of the entire service.

6. Cloned Documentation-Contd.
Medicare contractors consider records cloned when:
Each entry in medical record is worded exactly like or similar to the previous entries.
Medical documentation is exactly the same from patient to patient.
Cloning often occurs on claims for procedures that have specific sets of coverage criteria and is most often found as pre-printed, template-type and/or electronic health record notes.
Medicare contractor position: “Cloning of documentation will be considered misrepresentation of the medical necessity requirement for coverage of services”.
What makes this visit different/medically necessary from the previous visit, when both are recorded exactly the same?

7. 1995 VS. 1997 Documentation Guidelines
Many providers feel that the 1995 guidelines meet their needs more effectively as the documentation requirements aren’t as cumbersome and specific. That being said, the documentation will be less detailed then if the provider were using the 1997 guidelines.
Providers can choose to use either the 1997 or the 1995 guidelines, whichever is more advantageous to the provider.
It's hard to say that one set of rules is "better" because each version has advantages and disadvantages. You must choose to use one or the other. It is NOT ACCEPTABLE to mix and match elements from both sets of rules within the same note.

8. Evaluation & Management Services
The level of service billed is based on the following three key elements:
History
Exam
Medical Decision Making
Other contributory components would be:
Counseling
Coordination of care (with other providers)
Nature of presenting problem
Time (must be documented in record if used for level of service)

9. HISTORY: Chief Complaint
Every medical record must document a chief complaint (reason for visit).
Usually stated in the patients words
Example: Four year old boy complaining of bilateral ear pain, sore throat and fever.
Any note not containing a chief complaint will not meet any level of History as it is required for all E&M service levels.
The chief complaint does not have to be separately documented from the HPI.

10. Inappropriate example: Patient here for follow up
Chief Complaint
If the visit is strictly for follow up, the condition being followed must be documented.
Inappropriate example: Patient here for follow up
Appropriate Example: Patient is here for follow up regarding diabetes management.

11. History of Present Illness (HPI)
The HPI describes the patients current illness from the first sign and/or symptom to present or from the previous encounter to the present.
The HPI must be documented by the provider.
There are a total of 8 elements that can be used to describe the HPI.
Effective Sept. 30, 2013, when billing Medicare, you may combine the 1997 extended HPI elements along with the 1995 exam guidelines. (Status of 3 or more chronic conditions)

12. HPI Elements Location- Where the symptom is occurring
Quality- Describing the symptom or pain
Severity- Rating or describing the symptom or pain
Duration- How long has the pain or symptom been present
Timing- When the symptom occurs
Context- Instances that can be associated with the symptom.
Modifying Factors- Actions done to make symptom better or worse

13. HPI Elements, cont.
There are two levels of HPI:
Brief ( 1 to 3 elements)
Extended (4 or more elements)
Example: Patient complaining of left knee (location) pain for three days (duration).
Example: Patient complaining of sharp (quality) left knee (location) pain for three days (duration), worsens with weight bearing (context).

14. Review of Systems (ROS)
Positive or negative responses to questions that are asked of the patient. The ROS can be documented by the patient on a questionnaire or by medical staff. If the provider references this document, he/she would need to document it in the medical record. The provider would also need to date and sign the document to show that it was referenced.

15. Review of Systems A total of 14 systems
Constitutional Symptoms (usual weight, recent weight changes, fever, weakness, fatigue)
Eyes (Visual disturbance, glaucoma, cataracts, pain, redness)
Ears, Nose, Mouth, Throat (Hearing, discharge, tinnitus, dizziness, pain, head cold, soreness, redness, hoarseness, difficulty swallowing)
Cardiovascular (Chest pain, rheumatic fever, tachycardia, palpitation, elevated blood pressure, edema, faintness, varicose veins)
Respiratory (Chest pain, wheezing, cough, dyspnea, bronchitis)
Gastrointestinal (Appetite, thirst, nausea,, hematemesis, rectal bleeding, diarrhea, constipation)

16. Review of Systems (cont.)
Genitourinary (Urinary Frequency, pain, nocturia, hematuria, incontinence, menstruation changes, symptoms of menopause)
Musculoskeletal (Joint of muscle pain, stiffness, cramps, swelling, limitation in motor activity)
Integumentary (Rashes, eruptions, dryness, jaundice, changes in skin, hair or nails)
Neurological (Headaches, faintness, blackouts, seizures, tingling, tremors, memory loss, involuntary movements)
Psychiatric (Personality type, nervousness, mood, insomnia, nightmares, depression)
Endocrine (Thyroid trouble, heat or cold intolerance, excessive sweating, thirst, hunger or urination)
Hematologic/Lymphatic (Anemia, easy bruising or bleeding, jaundice, transfusions)
Allergy/Immunologic (Difficulty breathing, anaphylaxis, swelling, sneezing, runny nose or itchy eyes in response to food, medication or airborne allergens)

17. Three Levels of Review of Systems
Problem Pertinent (Inquires about the system directly related to the problem identified in the HPI) - 1 system
Extended (Inquires about the system directly related to the problem identified in the HPI and a limited number of additional systems) – 2 to 9 systems
Complete (Inquires about the system directly related to the problem(s) identified in the HPI plus ALL additional body systems) 10+ systems
What if the provider states, “ROS Negative”. This would not be appropriate as the auditor/reviewer of these records would not be able to determine what ROS elements were reviewed with the patient. The provider would need to document any pertinent positive or negatives responses and then indicate “all remaining ROS are negative”. The term “Non-contributory” brings up areas of concern as well. Does this mean the provider didn’t do it or that he/she did and it wasn’t relevant. Let’s take the guessing out of it. I recommend that our providers document , “Reviewed and non-contributory”.

18. PFSH - Past, Family & Social History
Past Medical History: Current medications, Prior illness/injuries, Operations & hospitalizations, Allergies or Age appropriate vaccinations.
Family History: Health status or cause of death related to parents, siblings and children. Diseases related to chief complaint, HPI or ROS; Hereditary or high risk diseases.
Social History: Living arrangements, Marital Status, Sexual history, use of drugs, alcohol or tobacco. Extent of education; Current employment.

19. What is your History Level?
History Type
Chief Complaint
HPI
ROS
PFSH
Problem Focused
Brief (1-3)
None
Expanded Problem Focused
Problem Pertinent
Detailed 4+
2-9
Pertinent (1)
Comprehensive
Complete (10+)
Complete (3)
Est. (2)
All three elements in the table must be met to qualify for a given type of history.
DO NOT count a given element more than once in determining a type of history. For example, an element counted in the HPI may not be counted again as an element of the ROS.
Review of system MUST be medically necessary for chief complaint. If patient presents for a ankle sprain you should not be checking the Genitourinary system!

20. What level of history is this??
10 year old boy presents today complaining of right wrist pain. He indicates that he was skate boarding yesterday and fell. Feels sharp pain when he grabs at objects. Mom indicates that Tylenol does seem to help a little. Review of system: Patient states wrist hurts with movement. No PFSH documented.

21. Code my level of history….
4 HPI Documented
Location- Right Wrist pain
Duration- Fell yesterday
Quality- Sharp pain
Modifying Factors- Tylenol helps a little
1 Review of Systems
Musculoskeletal
No Past, Family or Social History
History= Expanded Problem Focused

22. Exam Systems Constitutional (Vital signs, general appearance) Eyes
Ears, nose throat & mouth ( When auditing, verify all 3 areas are documented to give credit)
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic, lymphatic, immunologic

23. Based on four types of exams, using 1995 Guidelines
Levels of E&M Services
Based on four types of exams, using 1995 Guidelines
Problem Focused- A limited examination of the affected body area or organ system
Expanded Problem Focused- A limited examination of the affected body area or organ system and other symptomatic or related organ system(s)
Detailed- An extended examination of the affected body(s) and other symptomatic or related organ system(s)
Comprehensive- A general multi-System examination or complete examination of a single organ system(s)
According to a recent E/M training session provided by Noridian they state, “Examination is only one of three components
to determine level of service and may be least important”

24. Examination
An examination may involve several organ systems or a single organ system. The type and extent of the examination performed is based upon clinical judgment, the patient’s history, and nature of the presenting problem(s).
The 1995 documentation guidelines describe two types of comprehensive examinations that can be performed during a patient’s visit: general multi-system examination and single organ examination.
1997 Guidelines - A general multi-system examination involves the examination of one or more organ systems or body areas, as depicted in the chart on the next slide.

25. TYPE OF EXAMINATION
DESCRIPTION
Problem Focused
Include performance and documentation of one to five elements identified by a bullet in one or more organ system(s) or body area(s).
Expanded Problem Focused
Include performance and documentation of at least six elements identified by a bullet in one or more organ system(s) or body area(s).
Detailed
Include at least six organ systems or body areas. For each system/area selected, performance and documentation of at least two elements identified by a bullet is expected. Alternatively, may include performance and documentation of at least twelve elements identified by a bullet in two or more organ systems or body areas.
Comprehensive
Include at least eight organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least two elements identified by bullet is expected.*

26. 1997 Guidelines:
A single organ system examination involves a more extensive examination of a specific organ system, as depicted in the chart below

27. A single organ system examination involves a more extensive examination of a specific organ system, as depicted in the chart below.
Type of Examination
Description
Problem Focused
Include performance and documentation of one to five elements identified by a bullet, whether in a box with a shaded or unshaded border
Expanded Problem Focused
Include performance and documentation of at least six elements identified by a bullet, whether in a box with a shaded or unshaded border.
Detailed
Examinations other than the eye and psychiatric examinations should include performance and documentation of at least twelve elements identified by a bullet, whether in a box with a shaded or unshaded border.
Eye and psychiatric examinations include the performance and documentation of at least nine elements identified by a bullet, whether in a box with a shaded or unshaded border
Comprehensive
Include performance of all elements identified by a bullet, whether in a shaded or unshaded box.
Documentation of every element in each box with a shaded border and at least one element in a box with an unshaded border is expected

28. What level is your Exam?
Some important points that should be kept in mind when documenting general multi-system and single organ system examinations (in both the 1995 and the 1997 documentation guidelines) are:
Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. A notation of “abnormal” without elaboration is not sufficient.
Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or organ system(s) should be described.
A brief statement or notation indicating “negative” or “normal” is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s).

29. Counseling
Documentation of an Encounter Dominated by Counseling and/or Coordination of Care
When counseling and/or coordination of care dominates (more than 50 percent of) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting, floor/unit time in the hospital, or NF), time is considered the key or controlling factor to qualify for a particular level of E/M services. If the level of service is reported based on counseling and/or coordination of care, the total length of time of the encounter should be documented and the record should describe the counseling and/or activities to coordinate care.
The Level I and Level II CPT® books, which are available from the American Medical Association, list average time guidelines for a variety of E/M services. These times include work done before, during, and after the encounter. The specific times expressed in the code descriptors are averages and, therefore, represent a range of times that may be higher or lower depending on actual clinical circumstances.

30. Medical Decision Making
Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option, which is determined by considering the following factors:
The number of possible diagnoses and/or the number of management options that must be considered;
The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed; and
The risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the possible management options.

31. The chart below depicts the elements for each level of medical decision making. To qualify for a given type of medical decision making, two of the three elements must either be met or exceeded.
TYPE OF DECISION MAKING
# OF DIAGNOSIS OR MANAGEMENT OPTIONS
AMOUNT AND/ OR COMPLEXITY OF DATA TO BE REVIEWED
RISK OF SIGNIFICANT COMPLICATIONS, MORBIDITY, AND/OR MORTALITY
Straightforward
Minimal
Minimal or None
Low Complexity
Limited
Low
Moderate Complexity
Multiple
Moderate
High Complexity
Extensive
High

32. Number of Diagnoses and/or Management Options
The number of possible diagnoses and/or the number of management options that must be considered is based on:
The number and types of problems addressed during the encounter;
The complexity of establishing a diagnosis; and
The management decisions that are made by the physician
In general, decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem. The number and type of diagnosed tests performed may be an indicator of the number of possible diagnoses. Problems that are improving or resolving are less complex than those problems that are worsening or failing to change as expected. Another indicator of the complexity of diagnostic or management problems is the need to seek advice from other health care professionals.

33. IMPORTANT POINTS TO REMEMBER
For each encounter, an assessment, clinical impression, or diagnosis should be documented which may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation:
For a presenting problem with an established diagnosis, the record should reflect whether the problem is:
- Improved, well controlled, resolving, or resolved; or
- Inadequately controlled, worsening, or failing to change as expected.
For a presenting problem without an established diagnosis, the assessment or clinical impression may be stated in the form of differential diagnoses or as a “possible,” “probable,” or “rule out” diagnosis.
The initiation of, or changes in, treatment should be documented. Treatment includes a wide range of management options including patient instructions, nursing instructions, therapies, and medications.
If referrals are made, consultations requested, or advice sought, the record should indicate to whom or where the referral or consultation is made or from whom advice is requested

34. Amount and/or Complexity of Data to be Reviewed
The amount and/or complexity of data to be reviewed is based on the types of diagnostic testing ordered or reviewed. Indications of the amount and/or complexity of data being reviewed include:
A decision to obtain and review old medical records and/or obtain history from sources other than the patient (increases the amount and complexity of data to be reviewed);
Discussion of contradictory or unexpected test results with the physician who performed or interpreted the test (indicates the complexity of data to be reviewed); and
The physician who ordered a test personally reviews the image, tracing, or specimen to supplement information from the physician who prepared the test report or interpretation (indicates the complexity of data to be reviewed).

35. Some important points that should be kept in mind when documenting amount and/or complexity of data to be reviewed include:
If a diagnostic service is ordered, planned, scheduled, or performed at the time of the E/M encounter, the type of service should be documented.
The review of laboratory, radiology, and/or other diagnostic tests should be documented. A simple notation such as “WBC elevated” or “Chest x-ray unremarkable” is acceptable. The review may alternatively be documented by initialing and dating the report that contains the test results.
A decision to obtain old records or obtain additional history from the family, caretaker, or other source to supplement information obtained from the patient should be documented.

36. Complexity of Data, Cont.
Relevant findings from the review of old records and/or the receipt of additional history from the family, caretaker, or other source to supplement information obtained from the patient should be documented. If there is no relevant information beyond that already obtained, this fact should be documented. A notation of “Old records reviewed” or “Additional history obtained from family” without elaboration is not sufficient.
Discussion about results of laboratory, radiology, or other diagnostic tests with the physician who performed or interpreted the study should be documented.
The direct visualization and independent interpretation of an image, tracing, or specimen previously or subsequently interpreted by another physician should be documented.

37. Risk of Significant Complications, Morbidity, and/or Mortality
The risk of significant complications, morbidity, and/or mortality is based on the risks associated with the following categories:
Presenting problem(s);
Diagnostic procedure(s); and
Possible management options.
The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next encounter.

38. Medical Decision Making
The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. The highest level of risk in any one category determines the overall risk.
The level of risk of significant complications, morbidity, and/or mortality can be:
Minimal;
Low;
Moderate; or
High

39. Some important points that should be kept in mind when documenting level of risk are:
Comorbidities/underlying diseases or other factors that increase the complexity of medical decision making by increasing the risk of complications, morbidity, and/or mortality should be documented;
If a surgical or invasive diagnostic procedure is ordered, planned, performed or scheduled at the time of the E/M encounter, the type of procedure should be documented;
The referral for or decision to perform a surgical or invasive diagnostic procedure on an urgent basis should be documented or implied

40. Risk of Significant Complications, Morbidity, and/or Mortality, cont
Risk of Significant Complications, Morbidity, and/or Mortality, cont. The table on the next couple of pages may be used to assist in determining whether the level of risk of significant complications, morbidity, and/or mortality is minimal, low, moderate, or high. Because determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk.

43. New vs Established pts
No face-to-face professional services received from the physician or another physician of the same specialty and sub-specialty who belongs to same group practice for three years
Internal Medicine and Family Practice are considered different specialty
Patient seen by physician covering or on-call physician considered patient of usual doctor and is not a new patient

44. Medical Decision Making
Putting it together
History
Exam
Medical Decision Making
E&M

45. References
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services (Evaluation and Management Services Guide) “The Art of E&M Auditing” by Intelicode Per Internet Only Manual (IOM) Medicare Claims Processing Manual, Publication , Chapter 12, section