1. Documentation of E&M services
Presented by:
Karen Kvarfordt, RHIA, CCS-P, CCDS
President, DiagnosisPlus, Inc.
2014

2. What is documentation and why is it important?
Medical record documentation is required to record pertinent facts, findings, and observations about an individual’s health history.
Assists physicians and other health care professionals in evaluating and planning the patient’s immediate treatment and monitoring his/her health over time.
“If it isn’t documented, it didn’t happen”!

3. The Elements of Medical Documentation
The reason the patient presented to see the physician/provider.
Complete details of the information provided by the patient and by the evaluation of the patient.
The results of diagnostic, consultative, and/or therapeutic services provided to the patient.
The assessment of the patient conditions.
The plan for the care of the patient, including advice from other physician specialists.
Other services, procedures and supplies provided to the patient.
The time spent with the patient, if counseling or coordinating care was provided.

4. The Elements of Medical Documentation…
The style and form of medical documentation depends on the provider. However, it is important that any reader of the medical record be able to understand the service rendered and medical necessity for the service.
The medical documentation must be legible and understandable for all providers who care for the patient. If the handwriting of the physician cannot be read, Medicare auditors, as well as other payers, consider the service as not billable.

5. Illegible

6. Evaluating Your Documentation
Is the reason for the patient encounter documented in the medical record? Is the Chief Complaint documented by the physician? Is the diagnosis documented to the highest specificity?
Does the medical record clearly explain the medical necessity of the level of E&M service, diagnostic and therapeutic procedures, support services and supplies provided?
Is the assessment of the patient’s condition apparent in the medical record?
Medical record should tell the patient story!

7. Other Points to Consider
Documentation guidelines in the Evaluation and Management Services Guide also indicate that the documentation should be able to validate where the services were rendered and that the services were medically necessary and appropriate.
The ICD-9-CM & CPT codes reported on the UB (facility) & 1500 (professional) should be supported by the documentation in the medical record.

8. And a few more Points…
The history areas and medical decision making areas frequently suffer from lack of detail. It is common to see the words “Patient here for f/u” as the chief complaint and the HPI. This is insufficient as is “Patient here to establish MD.”
With decision making, the notations “continue present meds” and “f/u 3 months” tells nothing of the problem(s), the status of the problem, and the treatment or management of the problem.

9. What is an E&M Code?

10. Evaluation & management
E&M services refer to visits and consultations furnished by physicians and/or providers.
Billing for a patient visit requires the selection of a CPT code that best represents the level of E&M service provided.
Five (5) CPT codes that may be selected to bill for office or other outpatient visits for a “new” patient (99201 – 99205) and…
Five (5) CPT codes for an “established” patient (99211 – 99215).

11. New patient e&m
99201 – Usually the presenting problem(s) are self-limited or minor and the physician typically spends 10 minutes face-to-face with the patient and/or family. E&M requires the following three key components:
Problem focused history
Problem focused examination
Straightforward medical decision making

12. New patient e&m
99202 – Usually the presenting problem(s) are of low to moderate severity and the physician typically spends 20 minutes face-to-face with the patient and/or family. E&M requires the following three key components:
Expanded problem focused history
Expanded problem examination
Straightforward medical decision making

13. New patient e&m
99203 – Usually the presenting problem(s) are of moderate severity and the physician typically spends 30 minutes face-to-face with the patient and/or family. E&M requires the following three key components:
Detailed history
Detailed examination
Medical decision making of low complexity

14. New patient e&m
99204 – Usually the presenting problem(s) are of moderate to high severity and the physician typically spends 45 minutes face-to-face with the patient and/or family. E&M requires the following three key components:
Comprehensive history
Comprehensive examination
Medical decision making of moderate complexity

15. New patient e&m
99205 – Usually the presenting problem(s) are of moderate to high severity and the physician typically spends 60 minutes face-to-face with the patient and/or family. E&M requires the following three key components:
Comprehensive history
Comprehensive examination
Medical decision making of high complexity

16. New vs. established
To determine the appropriate level of service for a patient's visit, it is necessary to first determine whether the patient is ‘new’ or already ‘established’.
CPT 2012 Revised Definitions:
New - “A new patient is one who has not received any professional services from the physician or another physician of the exact same specialty and subspecialty who belong to the same group practice within the past three years”.

17. Established – “An established patient is one who has received professional services from the physician or another physician of the exact same specialty and subspecialty who belongs to the same group practice within the past three years”.
Exception! Patients seen in the Emergency Room do not have the distinction of ‘new’ vs. ‘established’.

18. Emergency Room ER providers use following CPT codes: 99281 99282 99283
Problem focused history & examination
Straightforward MDM
Usually presenting problem(s) are self limited or minor.
99282
Expanded problem focused history & examination
Low complexity MDM
Usually presenting problem(s) are of low to moderate complexity
99283
Moderate complexity MDM
Presenting problem(s) are of moderate severity

19. And a few more… 99284 99285 Detailed history and examination
MDM of moderate complexity
Usually the presenting problem(s) are of high severity, and require urgent eval by the physician but do not pose an immediate significant threat to life/physiological function
99285
Comprehensive history & exam and MDM of high complexity
High severity and pose an immediate significant threat to life/physiological function

20. Documentation guidelines
General multi-system exam (7 body areas or 12 body systems)
Problem Focused = 1
Expanded Problem Focused = 2-4
Detailed = 5-7
Comprehensive = 8 or more

21. Documentation guidelines
Multi-system exam or one of ten individualized single system exams
Get ‘credit’ for documentation of 3 or more chronic conditions
History and Medical Decision Making are the same for 1995 & 1997
CMS – Use whichever set of results is most in the physicians’ favor.
However, you can’t mix & match!

22. Documentation of E&M services
The three key components of E&M services are:
History
Physical Examination
Medical Decision Making
Please note that just because the E&M level is dependent on two or three key components, performance & documentation of one component, ie, examination, at the highest level does not necessarily mean that the encounter in its entirety qualifies for the highest level of E&M.

23. Chief Complaint (CC)
Chief Complaint – Each note must always include a chief complaint even if the chief complaint describes that the patient is presenting for follow-up of a previous problem, the reason for the visit must be clear as in “Patient presenting for f/u of uncontrolled hypertension.”
Usually stated in the patient’s own words.
Sometimes referred to as “presenting problem.”
Example: Patient complains of upset stomach, aching joints, or fever.

24. Key Components (History)
Information that is given by the patient to the physician
The history consists of 3 parts
History of Present Illness (HPI)
Review of Systems (ROS)
Past, Family, Social History (PFSH)
Remember! The Chief Complaint and the HPI must be documented by the physician.

25. Four types of history Problem Focused Required Brief N/A
TYPE OF HISTORY
CHIEF COMPLAINT
HISTORY OF PRESENT ILLNESS
REVIEW OF SYSTEMS
PAST, FAMILY, AND/OR SOCIAL HISTORY
Problem Focused
Required
Brief
N/A
Expanded Problem Focused
Problem Pertinent
Detailed
Extended
Pertinent
Comprehensive
Complete

26. Key Components (History)
History of Present Illness – Includes information described by the patient about the current condition including:
Location – refers to the location of the problem/symptoms – left lower quadrant; left leg; right arm; etc.
Severity – severity of the presenting problem – mild, severe; increasing; resolving, etc.
Timing – the interval of the pain or suffering – every night; constant; comes and goes; intermittent, etc.
Modifying Factors – how is the pain symptom modified – relieved by standing erect; better after taking aspirin; walking makes pain worse; etc.
Quality – descriptive adjective – dull; sharp; aching; stinging; throbbing, etc.
Duration – how long the patient has had the symptoms – two days; since last visit; since this morning, etc.
Context – describes how the symptoms began or occurred – after the auto accident; after eating out at a restaurant; when I sit down; etc.
Associated Signs and Symptoms – these are significant signs/symptoms that the patient feels are related to/part of their injury or illness – dizziness with nausea; swelling with injury; double vision with headache, etc.

27. History… Alternate HPI Example
Documentation of three chronic illnesses
Must be related to chief complaint
Status of each condition must be documented
Example
Chief Complaint (CC)
Follow-up of HTN & Lower Extremity Edema
HPI –
(1) Patient states that home BP readings have been 130/80 – 145/85 with Diovan. (2) Patient states legs are not as swollen at end of day. (3) She states that headaches are less frequent and severe. (4) She has also been able to lose some weight and has more energy.
Brief HPI consists of 1 to 3 elements of the HPI
Extended HPI consists of at least 4 elements of the HPI or the status of at least 3 chronic or inactive conditions

28. ROS (review of systems)
Review of Systems – Includes the patient’s “inventory” of signs and/or symptoms. These are most often answers to questions asked by the provider in order to establish a working diagnosis. Systems are:
Constitutional – weight loss, fever, chills, malaise, etc.
Ear, nose throat, and mouth – hearing loss, sinusitis, sore throat, oral cavities, etc.
Gastrointestinal – nausea, vomiting, diarrhea, constipation, ulcer, etc.
Integumentary – skin rashes, moles, dryness, lumps, pigmentation, etc.
Endocrine – polyuria, polydipsia, cold-heat intolerance, diabetes, etc.
Genitourinary – hematuria, nocturia, menopause, incontinence, etc.
Hematologic/Lymphatic – anemia, bruising, bleeding, lymph node enlargement, etc.
Eyes – diplopia, blurred vision, glasses, etc.
Cardiovascular – chest pain or pressure, palpitations, murmur, hypertension, etc.
Musculoskeletal – arthritis, joint stiffness, swelling, myalgias, gout, etc.
Neurologic – dizziness, syncope, seizures, vertigo, weakness, tremor, etc.
Allergic/Immunologic – allergies to medicine, food, etc./hepatitis, HIV, etc.
Respiratory – cough, wheezing, asthma, etc.
Psychiatric – depression, agitation, panic-anxiety, memory disturbance, etc.

29. More on ros…
The Review of Systems should be pertinent to the presenting problem – All pertinent positive and negatives should be documented. If all systems are reviewed, after the pertinent systems are documented, the statement “all other systems have been reviewed and are negative” will be appropriate for a complete review of systems.
If a separate form is used for the Review of Systems, it should be dated and initialed by the provider with pertinent comments noted. This can be referred to by documenting “Review of Systems as noted on face sheet dated __ __ ____ has been reviewed with the following changes”.
But be careful in using this statement! It is not necessary to have a complete ROS for a minor problem such as a sprained ankle or sinusitis. Right?

30. Three types of ros Problem Pertinent
Inquiries about the system directly related to the problem identified in the HPI.
The patient’s positive responses and pertinent negatives for the system related to the problem should be documented
In the following example, one system – the ear- is reviewed:
Chief Complaint: Earache
ROS: Positive for left ear pain. Denies dizziness, tinnitus, fullness or headache

31. Three types of ros Extended/Expanded Problem
Inquiries about the system directly related to the problem(s) identified in the HPI and a limited number (two to nine) of additional systems.
Patient’s positive responses and pertinent negatives for two to nine systems should be documented.
In the following example, two systems – cardiovascular and respiratory- are reviewed:
Chief Complaint: Follow-up visit in office after cardiac cath. Patient states “I feel great.”
ROS: Patient states he feels great and denies chest pain, syncope, palpitations, and shortness of breath. Relates occasional unilateral, asymptomatic edema of the left leg.

32. Three types of ros Complete
Inquiries about the system(s) directly related to the problem(s) identified in the HPI plus all additional (minimum of 10) body systems.
At least 10 organ systems must be reviewed with positive systems or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating “all other systems are negative” is permissible.
In the following example, 10 signs & symptoms are reviewed:
Chief Complaint: Patient complains of “fainting spell.”
ROS:
Constitutional: weight stable, + fatigue
Eyes: + loss of peripheral vision
Ear, Nose, Mouth, Throat: no complaints
Cardiovascular: + palpitations; denies chest pain, calf pain, pressure or edema
Respiratory: + shortness of breath on exertion
Gastrointestinal: appetite good, denies heartburn, + episodes of nausea
Urinary: denies incontinence, frequency, urgency, nocturia
Skin: + clammy, moist skin
Neurological: + fainting; denies numbness, tingling and/or tremors
Psychiatric: denies memory loss or depression. Mood pleasant.

33. Past, family & social history (PFSH)
May also be documented by “Refer to history on face sheet dated __ __ ____ with the following changes:”
Past Medical History – includes adult & childhood illnesses or trauma, vaccinations & screenings, past surgical history, past & current medications, allergies.
Family History – includes parents, siblings, children, genetic disease of the family or other family history.
Social History – Information about the patient’s habits and circumstances – smoking, alcohol, drug use; sexual orientation, marital status, living arrangements, occupation, education, religion, recent travel.

34. What if you can’t get the history from the patient?
History is unobtainable:
Patient is unconscious, mentally ill, unable to speak, intoxicated, etc.
No other source is available.
Document the reason why the patient is unable to communicate and also that no other source is available, if applicable.
Physician is given credit for PFSH if unable to obtain from the patient.

35. Physical exam Key Components of Physical Exam
Should be pertinent to the presenting problem, i.e. if an established patient is in for follow-up of allergic rhinitis, a head to toe exam is not necessary.
Should never, ever be copied forward from a previous visit.
Care should be taken when using a check off form with “Normal” – not just go down the line √ off systems!
Some auditors consider “WNL” as “We Never Looked.

36. General multi-system exam
TYPE OF EXAMINATION
DESCRIPTION
Problem Focused
Include performance and documentation of 1-5 elements identified by a bullet in 1 or more organ system(s) or body area(s).
Expanded Problem Focused
Include performance and documentation of at least 6 elements identified by a bullet in 1 or more organ system(s) or body area(s).
Detailed
Include at least 6 organ systems or body areas. For each system/area selected, performance & documentation of at least 2 elements identified by a bullet is expected. May include performance & documentaiton of at least 12 elements identified by a bullet in 2 or more organ systems or body areas.
Comprehensive
1997: Include at least 9 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 2 elements identified by bullet is expected.
1995: 8 organ systems must be examined. If body areas are examines and counted, they must be over and above the 8 organ systems.

37. 1997 documentation guidelines
The 10 single organ system examinations are:
Cardiovascular
Ear, Nose, Mouth and Throat
Eyes
Genitourinary (male & female)
Hematologic/Lymphatic/Immunologic
Musculoskeletal
Neurological
Psychiatric
Respiratory
Skin

38. Documentation guidelines of exam
Specific abnormal and relevant negative findings of the exam of the affected or symptomatic body area(s) or organ system(s) should be documented.
A notation of “abnormal” without elaboration is insufficient.
Brief statement or notation indicating ‘negative’ or ‘normal’ is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s).

39. Key Components Medical Decision Making
Number of diagnosis(es) or management options:
All known diagnoses that are being treated or affect treatment
Undiagnosed conditions that are being evaluated
Treatments being used, considered or planned
Plays the ‘primary’ role in determining the correct level of service

40. Amount &/or complexity of data to be reviewed
If a diagnostic service is ordered, planned, scheduled or performed at the time of the E&M visit, the type of service should be documented.
Review of labs or any diagnostic tests should be documented.
“WBC elevated” or “chest x-ray unremarkable” is acceptable. The review may be documented by initialing & dating the report that contains the test results.
Decision to obtain medical records or history from someone other than the patient must be documented.
“Old records reviewed” or “additional history obtained from the family” without further elaboration is not sufficient – no credit should be given.

41. Table of risk
Risk of significant complications, morbidity, and mortality is based on the risks associated with:
Presenting problem(s) or number of diagnoses and/or risk of complications (Chief Complaint)
Diagnostic procedures ordered
Possible management options

42. S O A P – Not the cleaning kind!
(S)ubjective
Chief Complaint – Each note must always include a chief complaint.
History of Present Illness
Review of Systems
Past Medical, Family and Social History

43. S O A P – Format (O)bjective
Physical Examination – Second of the three key components for evaluation and management is documented by the provider.
Amount and Complexity of Data
Review of tests, records, independent review of tracings, specimens, etc.

44. S O A P – Format (A)ssessment
Number of diagnoses: The following should be considered:
All known diagnoses that are being treated or affect treatment
Undiagnosed conditions that are being evaluated
Risk of complications and/or morbidity or mortality

45. S O A P – Format (P)lan Treatment Options:
Prescription drug management
Diagnostic tests
IV Fluids
Surgeries
Decision not to resuscitate
Return to Office
Referral to another physician
Physical, Occupational, Speech Therapy
Over the Counter Drugs

46. And then there is “Time”
Used in selecting an E&M code only when Counseling and/or Coordination of care represents more than 50% of the time spent face-to-face (outpatient) or bedside and on the floor or unit with the patient or family (inpatient).
Both time elements – total length of time for the visit and total length of time involved in Counseling and/or Coordination of care – as well as the nature of the counseling and/or coordination of care must be documented explicitly in the medical record.

47. Prolonged services
CPT codes are used when a physician provides prolonged services involving direct (face-to-face) patient contact beyond the usual service in either the inpatient or outpatient setting.
Reported in addition to E&M level.
Report the total duration of the face-to- face time spent even if not continuous.

48. More on prolonged services
Bill the first hour with CPT 99354, 99356
Each additional 30 minutes with CPT 99355,
Can only be reported ‘once’ per day
Less than 30 minutes is included in the E&M level
Example:
Physician performed a visit that met the definition of visit code & the total duration of the direct face-to-face services (including the visit) was 65 minutes.
Physician bills E&M and 1 unit of CPT

49. Inpatient Initial Hospital Care Subsequent Hospital Care
99221 (low severity – 30 minutes)
99222 (moderate severity – 50 minutes)
99223 (high severity – 70 minutes)
Subsequent Hospital Care
99231 (Stable, recovering or improving – 15
minutes at bedside)
99232 (Responding inadequately/developed
minor complication – 25 min)
99233 (Unstable/developed significant
complication or new problem – 35 min)

50. Discharge day management
Documentation does not always include the total time spent performing the discharge day management function
Review of the medical record
Completion of discharge summary
99238
Less than 30 minutes
99239
More than 30 minutes
CPT Default:
If time is not documented, then the lesser of the two is billed, i.e.,

51. Critical care
Requires ‘direct personal management’ from a physician, the absence of which ‘would likely result in sudden, clinically significant or life-threatening deterioration’ of the patient.
Examples:
Acute allergic reaction(s)
GI bleed
Subdural/subarachnoid hemorrhage
AMI
Respiratory distress/failure

52. Critical care Critical Care is a ‘time’ driven CPT code.
Does not require constant bedside attendance.
Reviewing ancillary studies
Discussions with nursing staff, physicians, family members & documentation of these interventions in the medical record
Billable procedure include (but not limited to):
Endotracheal intubation
CPR
Chest tube placement
CVP line insertions
EKG interpretation

53. More on critical care
Physician(s) MUST document critical care for the encounter in the record.
State the time spent providing critical care in minutes:
99291 = documented minutes
99292 = Each additional 30+ documented
minutes
The HPI & ROS guidelines are not required for Critical Care, however, documentation does need to support medical necessity for the high level of service.

54. If it is NOT documented, it did NOT happen!
The Golden Rule
If it is NOT documented, it did NOT happen!

55. Karen Kvarfordt, RHIA, CCS-P, CCDS President, DiagnosisPlus, Inc
Karen Kvarfordt, RHIA, CCS-P, CCDS President, DiagnosisPlus, Inc. PO Box 486 Pocatello, ID (208) Fax: (360)