Documentation Requirements for

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Documentation Requirements for

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Title: Documentation Requirements for

1

Documentation Requirements for
Evaluation Management
Services

2
Presentation Goals

Introduce the 3 Key Components to an E/M Service
History
Examination
Medical Decision Making
Introduce the UC Davis Health System Audit Tool,
version 2.4
Review time and how it may effect a level of
service
Review critical care documentation guidelines
Review Teaching Physician Guidelines

3
Overview of E/M Services

Classification of Common E/M Services
Office or Other Outpatient Services
New Patient 99201-99205
Established Patient 99211-99215
Consultations
Office or Other Outpatient Consultations 99241-99
245
Initial Inpatient Consultations 99251-99255
Hospital Inpatient Services
Initial Hospital Care 99221-99223
Subsequent Hospital Care 99231-99233
Hospital Discharge Services 99238-99239
Emergency Department Services
New or Established 99281-99285
Critical Care
Over 24 months of age 99291-99296
Preventive Medicine
Initial Preventive Medicine 99381-99387
Established Patient 99391-99397

4
Overview of E/M Services

Classification of Other E/M Services
Nursing Facility/SNF/Rest Homes, etc 99304-99350
Prolonged Services 99354-99359
Care Plan Oversight 99374-99380

5
Overview of E/M Section

Code assignment in the CPT E/M Section vary
according to three factors
Place of Service
office, hospital, emergency room, nursing home
Type of Service
consultation, admission, office visit
Patient Status
new patient, established patient, inpatient,
outpatient
Each E/M category includes three to five levels
of service
The levels indicate the wide variations in skill,
time, effort, responsibility
and knowledge required to diagnose, treat or
prevent an illness or injury

6
Overview of E/M Section

In a Teaching Setting, a fourth factor needs to
be considered
Reimbursement Factor(s)
Performing Provider vs Billing Provider (NP/PA vs
MD)?
Are there additional Payor Specific Guidelines
(Medi-cal/Medicare)?
Have the documentation guidelines been met?
Is the clinician (NP/PA) on the Hospital Cost
Report?

7
Overview of E/M Section

All providers who are licensed to provide medical
services may use the same
E/M codes for reporting their services regardless
of specialty
The specific level is referring to the last digit
in each E/M service code for
example, a 99201 is referred to as a New
Patient, level 1
This level requires meeting or exceeding the
following Three Key
Components
a problem focused History
a problem focused Exam
straightforward Medical Decision Making

8
Overview of E/M Section

The E/M levels are selected based on the
clinicians documentation
Therefore, it is important that the clinician
documents each patient
encounter as accurate and complete as possible
What should be considered when analyzing the
patients medical record?
Does the documentation justify the medical
necessity of the service and/or procedure
performed?
Does the documentation support the level of
service reported?
Is the documentation legible?
Are there specific payer documentation guidelines
and have they been met?

9
Overview of E/M Section

Medical Necessity
Medicare defines "medical necessity" as services
or items reasonable
and necessary for the diagnosis or treatment of
illness or injury or to
improve the functioning of a malformed body
member
Clinician vs Coder
Questions regarding an extensive write up for a
minor problem should be referred back to the
clinician for clarification

10
Overview of E/M Section

Medicare-Selection of Level of E/M Service
The CMS Manual, Publication 100-4, Chapter 12,
30.6.1 - Selection of
Level of Evaluation and Management Service states
the following
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.

11
Overview of E/M Section

Medicare-Selection of Level of E/M Service, cont
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. The service should be
documented during, or as soon as practicable
after it is provided in order to maintain
an accurate medical record.
Instruct physicians to select the code for the
service based upon the content of
the service.
The duration of the visit is an ancillary factor
and does not control the
level of the service to be billed unless more
than 50 percent of the face-to-face time
(for non-inpatient services) is spent providing
counseling or coordination of care.

12
Overview of E/M Section

E/M Guidelines
There are two guidelines that may be utilized,
1995 or 1997
Providers/Coders may use either guideline
Whichever is most advantageous to the provider
Must follow one guideline per patient encounter
Cannot mix and match

13
Overview of E/M Section

1995
Based on the number and/or extent of body areas
or organ systems examined
1997
Based on the examination of specific bulleted
items identified within a body area or organ
system

14
E/M Terms

New Patient
According to the American Medical Association, a
new patient is one who has not received any
professional services from a given physician or
another physician of the same specialty who
belongs to the same group practice within the
past three (3) years
Established Patient
According to the American Medical Association, an
established patient is one who has received
professional services from that physician or
another physician of the same specialty within
the same group within the past three (3) years
Consultations
A type of service provided by a licensed provider
whose opinion or advice regarding evaluation
and/or management of a specific problem is
requested by another licensed provider or
appropriate source. For example, a Physician, NP,
PA

15
E/M Terms

Consultations vs Referral
Consultation
Services rendered to give advice or an opinion to
a requesting provider about a patients diagnosis
and/or management of a condition
The 3 Rs
Request
Render opinion
Report
Referral
Transfer of care
Referring provider transfers the responsibility
for managing the patients complete care for a
condition to the receiving physician and the
receiving physician documents approval of care

16
E/M Services

Remember, documentation must support the medical
necessity and the level of service
Billed. The Level of Service is based on the
documentation of the 3 Key Components
and the Contributing Factors
3 Key Components
History
Examination
Medical Decision Making
Contributing Factors
Nature of Presenting Problem
Time
Outpatient Setting (Counseling by Provider
face-to-face)
Inpatient Setting (Counseling by Provider
face-to-face and/or Coordination of Care)

17
E/M History Component

Now lets take a look at the History Component on
the Audit
Tool
The History is divided into four levels
Problem Focused
Expanded Problem Focused
Detailed
Comprehensive
These levels are determined by

18
E/M History Component

Four Elements
History levels are determined by the following 4
elements
Chief Complaint (CC)
History of Present Illness (HPI)
Review of Systems (ROS)
Past, Family, and/or Social History (PFSH)
The extent of the history is dependent upon
clinical judgment and on the nature of the
presenting problem(s)
Not all histories will have or need all elements

19
E/M History Component

The Four Elements of History
Chief Complaint (CC)
A concise statement describing the symptom,
problem, condition, diagnosis, or other factor as
the reason for the encounter. Examplea return
visit recommended by the physician
History of Present Illness (HPI)
Describes the patients developing
condition/problem from the first sign and/or
symptom or from the previous encounter to the
present or the status of three chronic or
inactive conditions
Review of Systems (ROS)
An inventory of body systems obtained through a
series of questions seeking to identify signs
and/or symptoms the patient may be experiencing
or has experienced
Past, Family, and Social History (PFSH)
Review of the patients past history, family
history, and social history

20
E/M History Component

Chief Complaint
The reason for seeking medical care should be
recorded in the patients own words
Patient complains of left foot pain due to fall
last month.

21
E/M History Component

The History of Present Illness (HPI)
Two types
Brief HPI
1 to 3 HPI Elements
Extended HPI
4 or more HPI Elements or the status of at least
3 chronic or inactive conditions

22
E/M History Component

The HPI Elements
Location Where the symptom or problem is
occurring
Abdomen, chest, leg, arm, head
Severity - A rating or description of severity
of the symptom or pain
Bad, intolerable, minimal, slight
Timing When symptom or pain occurs
Before bed, upon waking, two hours after taking
medicine, continuous
Quality The character of the sign or symptom
Burning, dull, puffy, puss-filled, red, itchy
Duration How long a pain or symptom lasts, has
been present, or persisted
For two months, since prescription began
Associated signs/symptoms Any organ system or
body area complaints associated with the chief
complaint
Rash with blistering, nausea and vomiting,
abdominal pain
Context Instances or items that can be
associated with the chief complaint
When walking, in company of smokers, at work
Modifying factors Actions taken or things done
to effect the symptom or pain, making it better
or worse
Improves when lying down, worse after eating

23
E/M History Component

The HPI
Example of an extended HPI with 4 or more
elements
HPI For the past two days she has had chills,
fever and muscle aches. She feels worse in the
evening. Her illness is so severe she has not
been able to work.
Duration
Associated Signs
Timing
Severity

24
E/M History Component

The HPI
Extended HPI with status of at least three
chronic or inactive conditions.
Example
The patient is currently under my care for the
management of hypertension controlled with diet
and exercise, diabetes controlled with insulin,
and asthma requiring inhaler twice daily.

25
E/M History Component

The Review of Systems (ROS)
ROS includes 14 systems
Constitutional symptoms (fever, weight loss, etc)
Eyes
Ears, nose, mouth, throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary (skin and/or breast)
Neurological
Psychiatric
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic

26
E/M History Component

The ROS
ROS has 3 types
Problem Pertinent
1 system
Extended
2-9 systems
Complete
10 or more systems

27
E/M History Component

The ROS
Medicare Documentation Guidelines
Problem Pertinent ROS
The patient's positive responses and pertinent
negatives for the system related to the problem
should be documented.
Extended ROS
The patient's positive responses and pertinent
negatives for two to nine system should be
documented.
Complete ROS
At least ten organ systems must be reviewed.
Those systems with positive or pertinent negative
responses must be individually documented. For
the remaining systems, a notation indicating all
other systems are negative is permissible. In
the absence of such a notation, at least ten
systems must be individually documented.

28
E/M History Component

The ROS
Example of a complete ROS
The provider can list pertinent findings in 2 or
more systems and note all
other systems are negative
A patient is seen in the physicians office with
flu-like symptoms. For the past two days she has
had chills, fever, and muscle aches. She feels
worse in the evening. Her illness is so severe
she has not been able to work. (Provider queries
patient on at least ten systems, notes pertinent
findings) She has lost 7 pounds in the last
month. She denies abdominal pain, diarrhea, and
vomiting. All other systems are negative.
Constitutional
Gastrointestinal
All other systems are negative gives provider
credit for a complete ROS

29
E/M History Component

The Past, Family, and Social History (PFSH)
Past History
The patients past experience with illnesses,
operations, injuries and treatments
Family History
A review of medical events in the patients
family, including diseases that may be hereditary
or place the patient at risk
Social History
Age appropriate review of past and current
activities

30
E/M History Component

The PFSH
There are two types of PFSH, pertinent and
complete
The required elements for each differs based on
the patient status
New patient status
Pertinent
1 specific item from any of the 3 history areas
Complete
1 specific item from each of the 3 history areas
Established patient status
Pertinent
1 specific item from any of the 3 history areas
Complete
1 specific item from any 2 of the 3 history areas

31
E/M History Component

The PFSH
If the PFSH is non-contributory a statement is
required in the documentation to qualify it for
a complete PFSH
Example
Reviewed PFSH, non-contributory to current
condition.
For those categories of E/M services that require
only an interval history, it is not necessary to
record information about PFSH
Example
Subsequent hospital care
Subsequent nursing facility care

32
Overall History Component

Each history element must be met or exceeded to
determine
an overall history level
Lets look at an example
CC
Must be present in patients medical record
HPI
Extended
ROS
Complete
PSFH
Pertinent
Overall History level Detailed

33
E/M History Component

Example Outpatient Grid

34
E/M History

Caveat
Patient is unable to speak
Physician must document this
Patient intubated, unable to obtain History
Provider gets credit for a complete History!

35
E/M Examination Component

Now lets look at the Examination Portion of the
Audit Tool
Four Levels
Problem Focused
Expanded Problem Focused
Detailed
Comprehensive
Exam Elements
Body Areas
Organ Systems
(Cannot combine Body Areas and Organ Systems for
Comprehensive Exam)
2 Types
Multi-system
Single Organ System

36
E/M Examination Elements
37

38
E/M Medical Decision Making Component

Now lets look at the Medical Decision Making
Portion of the Audit Tool
Four Levels
Straightforward
Low Complexity
Moderate Complexity
High Complexity
To determine the level of Medical Decision
Making, two of the three following Elements must
meet or exceed
Elements
Number of Diagnoses or Treatment Options
Amount and/or Complexity of Data to be Reviewed
Risk of Complication and/or Morbidity/Mortality

39
E/M Medical Decision Making Component

Number of Diagnoses or Treatment Options
3 Categories
Self-limited or minor
stable, improved or worse
Established problem
stable, improved, worsening
New problem to examiner
no additional work up planned
additional work-up planned

40
E/M Medical Decision Making Component

1.
Self-limited or minor (stable, improved or worse)
Sore throat
Earache (simple)
Simple laceration
This category does not indicate that the problem
is new or established
American Medical Association (AMA)
A problem that runs a definitive and prescribed
course, is transient in nature, and is not likely
to permanently alter health status or has a good
prognosis with management/compliance.

41
E/M Medical Decision Making Component

2.
Established problem stable, improved
For this provider/specialty group usually
diagnosis and treatment has already been started
Established problem worsening
For this provider/specialty group must be
documented or CLEARLY implied, (pain has
increased, etc.)

42
E/M Medical Decision Making Component

3.
New problem to examiner no additional work- up
planned
New problem to examiner additional work-up
Planned
Starting treatment does not constitute
additional work-up.
Any diagnostic study or plan to help find a
definitive diagnosis.
Example
Radiology
Laboratory
Consultation with another physician

43
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44
E/M Medical Decision Making Component

Amount and/or Complexity of Data to be Reviewed
Review /or order of clinical lab tests
Review /or order in the radiology section of the
CPT
Review /or order of tests in the medicine
section
Discussion of test results with performing
physician
Decision to obtain old records /or history from
someone other than patient
Review and summarization of old records /or
obtaining history from someone other than patient
/or discussion of case with another health care
provider
Independent visualization of image, tracing or
specimen itself (not simple review of report)

45
E/M Medical Decision Making Component

Review /or order of clinical lab tests
Any documentation of the review of tests
previously ordered
Example(s)
Test results documented in notes
Documentation that Provider reviewed results
Documentation that indicates tests are ordered

46
E/M Medical Decision Making Component

Review /or order in the radiology section of the
CPT
Review of Report not actual film
Example(s)
Documentation of review of x-ray report
Documentation that a x-ray was ordered
Not viewed in Stentor (review of actual film)

47
E/M Medical Decision Making Component

Review /or order of tests in the medicine
Section
Report(s) is reviewed or ordered
Example(s)
EKG Report
Stress Test
Documentation that a medicine test was ordered

48
E/M Medical Decision Making Component

Discussion of test results with performing
physician
Discussion verbal communication and NOT a
report or letter
Example
Pathologist viewing specimen then pages ordering
MD to discuss results
PCP MD pages MD Specialist to discuss test results

49
E/M Medical Decision Making Component

Decision to obtain old records /or history from
someone other than
patient
Documentation should support the reason/need to
get old records or obtain the history from
someone other than the patient
Does not include
Parents of pediatric patient
Interpreter

50
E/M Medical Decision Making Component

Review and summarization of old records /or
obtaining history from
someone other than patient /or discussion of
case with another
health care provider
Summarize the review of old record or history and
document how it pertains to the patients current
problem
It must be Additional/Relevant information

51
E/M Medical Decision Making Component

Independent visualization of image, tracing or
specimen itself (not simple review of written
report)
Does not include
Rapid Strep Test
Urine Pregnancy Test
Does include
Reviewing image in Stentor, etc.
EKG Strip

52
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53
E/M Medical Decision Making Component

Risk of Complication and/or Morbidity/Mortality
Four Levels
Minimal
Low
Moderate
High

54
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55
Final Medical Decision-Making Level

2 of the 3 Elements must be met or exceeded
Number of Diagnosis or Treatment Options
Amount and/or Complexity of Data Reviewed
Risk of Complication and/or Morbidity/Mortality

56
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57
Example of Medical Decision Making

Number of Diagnoses or Treatment Options
Assessment The diabetes is controlled with diet
and exercise, blood glucose levels are within
acceptable limits. The high blood pressure that
we have been monitoring and trying to control
with diet and exercise is now far above an
acceptable range. The first problem is considered
an established stable problem while the blood
pressure is an established problem worsening.
Established Problem Stable Improved
Established Problem Worsening

58
Example of Medical Decision Making

Amount /or Complexity of Data Reviewed
The patient comes in for a recheck of diabetes
that is controlled with diet and exercise, blood
glucose levels are within acceptable limits, and
high blood pressure that you have been monitoring
and trying to control with diet and exercise is
through the roof. A CBC, Chemical profile,
urinalysis,electrocardiogram, and chest x-ray are
ordered.
Review /or order of clinical lab tests
Review /or order of tests in the medicine
section of CPT
Review /or order in the radiology section of CPT

59
Example of Medical Decision Making

Risk of Complications /or Morbidity of Mortality
The patient comes in for a recheck of diabetes
that is controlled with diet and exercise, blood
glucose levels are within acceptable limits, and
high blood pressure that you have been monitoring
and trying to control with diet and exercise is
through the roof. A CBC, Chemical profile,
urinalysis,electrocardiogram, and chest x-ray are
ordered. Impression 1. Diabetes-controlled. 2.
Hypertension- uncontrolled. Atenolol 50 mg
prescribed. The patient is to return in one week
for recheck.
1 or more chronic illnesses with mild
exacerbation, progression or side effects of
treatment
Lab test requiring venipuncture/CXRs/ECG
Prescription Drugs

60
Contributing Factors

Time
The American Medical Association guidelines state
that when counseling and/or coordination of care
dominates (MORE THAN 50) the physician/patient
and/or family encounter (face-to-face time) then
time may be considered the key or controlling
factor to qualify for a particular level of E/M
services
Documentation of time is key if time is the
determining factor
The total amount of time spent with the patient
must be clearly documented
The record should describe the counseling and/or
activity to coordinate care
A total of 30 minutes was spent with the
patient, more than half of this time was spent
discussing treatment options and subsequent
effects of chemotherapy.

61
Time

Typical Times
New Office Visit 99201-10 99202-20 99203-30 99204
-45 99205-60
Office Consult 99241-15 99242-30 99243-40 99244-6
0 99245-80
Inpatient Consult 99251-20 99252-40 99253-55 9925
4-80 99255-110
Established Office Visit 99211-
5 99212-10 99213-15 99214-25 99215-40
Initial Hospital Observation 99218-30 99219-50 992
20-70
Initial Hospital Visit 99221-30 99222-50 99223-70
Subsequent Hospital Visit 99231-15 99232-25 99233-
35

62
E/M Critical Care

Critical Care
Definition
Critical care is the care of critically ill or
critically injured patients who require the full,
exclusive attention by a physician(s). A
critical illness or injury acutely impairs one
or more vital organ systems such that there is
high probability of imminent or life threatening
deterioration in the patients condition.

63
E/M Critical Care

Critical Care, cont
Documentation Requirements
Since critical care is a time-based code, the
physician progress note must contain
documentation of the total time involved
providing critical care services. In a teaching
environment, the time recorded as critical care
time is the actual time spent by the physician,
not a resident, fellow, or allied health
provider. The time must be personally documented
by the teaching physician. Teaching time does
not count toward critical care time. Critical
care of less than 30 minutes duration on any
given day is reported with an evaluation and
management code.

64
E/M Critical Care

Critical Care, cont
Example Documentation
Patient seen and examined with Dr. Resident.
Reviewed and agree with his note and the plan of
care we developed together.
One hour of critical care time personally
performed due to patients hemodynamic
instability. Patient was resuscitated with 2
units of packed red blood cells. Obtained
additional studies to determine possible causes
for patients instabilities.

65
E/M Teaching Facility

Teaching Facility
Documentation requirements for State and Federal
Payers
The teaching physician saw the patient
The teaching physician reviewed the residents
note, and agreed or revised the findings
The teaching physician actively participated in
the care by either documenting involvement in the
development of the plan or by changing the plan

66
E/M Teaching Facility

Teaching Physician
Examples of minimally acceptable documentation
I saw the patient with the resident and agree
with the residents findings and plan we
developed.
I saw and evaluated the patient. Discussed with
the resident and agree with the residents
findings and plan we developed as documented in
the residents note.
See the residents note for details. I saw and
evaluated the patient and agree with the
residents findings and plans we developed as
written.

67
E/M Teaching Facility

Teaching Physician
Examples of unacceptable documentation for State
and Federal Payers
Agree with above.
Rounded, Reviewed, Agree.
Discussed with resident. Agree.
Seen and Agree.
Patient seen and evaluated.
A legible countersignature and/or identity alone
does not meet State and Federal payer requirements

68
E/M Teaching Facility

Teaching Physician
Non-State and Non-Federal Documentation
Requirements
(Commercial Payers)
Minimum evidence of review by the attending shall
be demonstrated by countersignature in the
patient medical record
Other requirements
The teaching physician shall be promptly
available
If the service includes direct patient contact,
the teaching physicians availability must
include the ability to be physically present to
review the residents note and ensure the
services were furnished appropriately

69
E/M Teaching Facility

Medical Students
The teaching physician and/or resident must
reference the medical students dated
documentation
The medical students documentation may only
contribute in two elements of the History
component
The Review of Systems and the Past Medical,
Family, Social History (ROS and PFSH)

70
E/M Differences, Inpatient vs Outpatient

Inpatient Encounters vs Outpatient Encounters
Inpatient Encounters
Key Components are the same
History
Examination
Medical Decision Making
Elements within each component are the same
Difference
Levels
Example Initial HP has 3 levels, not 5
Number of Elements Required
Example Initial HP requires a Complete ROS (10
or more systems) for levels 2 and 3

71
E/M Differences, Inpatient vs Outpatient