“If it isn’t documented, it hasn’t been done”

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”