Evaluation and Management Appropriate Level Selection and Documentation Compliance
**Includes a Quick E/M level selection guide**
WHAT
DO PAYERS WANT AND WHY?
Health care insurance companies may
require reasonable documentation to ensure that a service is consistent with
the patient’s insurance coverage and to validate:
ü The site of
service;
ü The medical
necessity and appropriateness of the diagnostic and/or therapeutic services
provided; and/or
ü That services
furnished have been accurately reported.
WHAT DO PAYERS
LOOK FOR?
ü Complete and
legible medical notes
ü Reason for the
encounter and relevant history, physical examination, findings, and prior
diagnostic test results
ü The patient’s
progress, response to and changes in treatment, and revision of diagnosis
should be documented
ü Assessment,
clinical impression, or diagnosis
ü Medical plan of
care
ü Date and legible
identity of the observer.
SELECTING THE BEST
CPT CODE
When
billing for a patient’s visit, select codes that best represent the services
furnished during the visit.
Billing
for an E/M service requires the selection of the CPT code that best represents:
Patient
type;
1.
New
Patient
2.
Established
Patient
Settings
of service;
1.
Office
or other outpatient setting
2.
Hospital
inpatient
3.
Emergency
department (ED)
4.
Nursing
facility (NF)
E/M LEVEL
There
are three key components when selecting the appropriate level of E/M service;
Ø
History
Ø
Examination
Ø
Medical
Decision Making
Counseling
and/or coordination of care are an exception to this rule, the key to qualify
for a particular level is the TIME.
HISTORY
Chief
Complaint (CC) is required for all E/M levels. It describes the reason for the
encounter.
History
of present illness (HPI) is a description of the development of the patient’s
present illness. There are two types of HPIs: Brief and extended. ***See the
image attached ***
REVIEW OF SYSTEMS (ROS)
ROS
is a review of body systems in order to identify signs and/or symptoms. There
are three types of ROS: problem pertinent, extended and complete. ***See the
image attached ***
PAST, FAMILY
and/or SOCIAL HISTORY (PFSH)
There
are two types of PFSH; Pertinent and complete. ***See the image attached ***
Ø
Past
history includes previous illness, surgeries, injuries and treatments.
Ø
Family
history includes hereditary conditions that may place the patient at risk
Ø
Social
history is an age appropriate review of activities (drinks, sports, etc.)
EXAMINATION
The
levels of E/M services are based on four types of examination:
Ø
Problem Focused – limited examination
of the affected body area or organ system.
Ø
Expanded Problem Focused - limited
examination of the affected body area or organ system and any other symptomatic
body area or organ system.
Ø
Detailed – extended examination
of the affected body area or organ system and any other symptomatic body area
or organ system.
Ø Comprehensive – general
multi-system examination or complete examination of a single organ (and other
symptomatic body area or organ system).
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:
ü
The
number of possible diagnoses and/or the number of management options that must
be considered;
ü
The
amount and/or complexity of medical records, diagnostic tests, and/or other information
that must be obtained, reviewed, and analyzed; and
ü
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.
GENERAL E/M DOCUMENTATION GUIDELINES
In
order to maintain an accurate medical record, services should be documented
during the encounter or as soon as practicable after the encounter.
The
diagnosis and treatment codes reported on the health insurance claim form or billing
statement should be supported by the documentation in the medical record.
It
is the provider’s responsibility to ensure that the submitted claim accurately
reflects the services provided.
The
provider must ensure that medical record documentation supports the level of service
reported to a payer.
If
a previously obtained ROS and/or PFSH is updated an evidence must be recorded
in the record describing any new information and the change date.
The
ROS and/or PFSH can be obtained by ancillary staff. However there must be a
notation from the physician supplementing or confirming the information
recorded by others.
If
the physician is unable to obtain the history, the physician should describe
the patient’s condition.
Specific
abnormal and relevant negative finding during the examination must be described.
A notation of “abnormal” is not
sufficient.
The
initiation or changes in treatment, surgical or diagnostic procedures ordered,
planned or scheduled at the time of the encounter should be documented.
If
referral is made the documentation should indicate the consultation details. (Whom,
where, etc.)
If
a diagnostic service is ordered, planned, scheduled or performed at the time of
the encounter it should be documented as well as the review of any diagnostic
test. (Radiology, labs etc.)
Direct
visualization or independent interpretation of images, tracings, etc. should
also be documented.
In
addition to the individual requirements associated with the billing of a
selected E/M, the service must also be considered reasonable and necessary.
Therefore, the service must be:
ü
Furnished
for the diagnosis, direct care, and treatment of the beneficiary’s medical
condition (that is, not provided mainly for the convenience of the beneficiary,
provider, or supplier); and
ü
Compliant
with the standards of good medical practice.
Today’s Tip
“Remember
to add the correct place of service (POS) on your bill. If you enter the
incorrect POS to your E/M service bill your claim will be automatically deny”
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