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Audit Challenges with E/M Services
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Can the term "non contributory" be used for PFSH?
For inpatient rounding E/M servcies, is a chief complaint
required for every note?
If ROS is unavailable due to patient being intubated in a
coma can credit be given if they note what all they did to
tery and collect the ROS?
If an established patient presents to the office location and
the provider documents a detailed history and exam but the
overall medical decision making is of "low complexity,"
how would you code this service? The risk would be
moderate. Would this be a 99213 or 99214?
For inpatient rehab-can a chief complaint be pulled from
the assessment?
It depends upon your MAC carrier. Some allow the use,
while others require that the specific questions asked be
Yes the chief complaint is still required. Each note must be
able to stand alone.
Yes. The provider just needs to indicate why the ROS was
It depends if you are using MDM as a required element for
2 of the 3 key components. If you are then the correct code
selection would be 99213. If not then you would look at
the nature of the presenting problem to see if using the
history and exam as your 2 components is appropriate and
code 99214. You need to consider possible overdocumentation when using just history and exam. Also,
you would need to know what your MAC carrier allows.
For all visits types CMS does state that the CC can be
inferred from the HPI. It does not state it can be inferred
from the Assessment and plan however we can use the
entire record. Just use caution and do not count plan
elements for HPI. Because this is a grey area you should
define in your practice.
Follow up to my ROS you give the provider a You could allow a complete ROS as if 10+ systems were
score of comprehensive ROS or how else would you score documented.
When the provider states "HPI/ROS/PFSH" same as from
prior visit, does the same level of history from the prior
visit carry over?
I would not recommend using the HPI documentation from
a previous visit. CMS states that the ROS and PFSH can
be referenced from previous visits, they do not say the HPI
can. The definition of the HPI implies that these
documented elements need to be a description of events
from the previous visit or from the first sign/symptom to
the present.
For established visits, it seems that many carriers require
MDM as one of the elements (out of 3) . Is this correct?
Correct. You need to know what your MAC carrier
requires. Requiring MDM as 2 of the 3 supports the
medical necessity of the E/M level. We work with
practices that even though their MAC may not require
MDM for 2 of the 3, they do and have made this a
requirement as part of their compliance standards.
What is the source document for slide 12?
CMS Internet Only Manual (IOM) Medicare Claims
Processing Manual, Publication 100-04, Chapter 12,
Section 30.6.1,
The link that I had no longer is in use. I will have research
and get back to you.
Do you have the CMS regulation that states they have
adopted the Marshfield guidelines or a reference for us to
Can we pull something from the chief complaint to use in
the HPI?
If the provider documented the chief complaint and
included elements of HPI then yes, you could count these
elements towards you HPI. You do not want to count
elements more than once. If the provider did not document
the CC then no, this would not be best practice.
At what point in the audit process do you make a note non- In this example the entire service does not need to be nonbillable, other than the blatant omissions. Example: Do
billable. If the date can be inferred or an amendment done
you make a consult non-billable if the providers does not
then you could bill using a different E/M category.
have a date and/or referring physician in his note, although
he dictated on the date he saw the patient.
When auditing a note and determining the MDM level,
how would you score results from lab work or x rays that
are pulled forward from a previous note. Also, if the
provider orders the test on 1 date and reviews the results
on the next date of service, would you give credit for
reviewing/ordering test on both dates of service?
If the EHR system auto populates previous tests, it would
be appropriate to count toward the MDM. However, if the
provider references these test or pulls the tests
himself/herself then you could. Tests that are pending are
counted in MDM under DATA as tests "ordered" or
reviewed. You could also count this a new problem with
work up IF in fact the problem is new to the provider.
Isn't it required that out of the 2/3 for MDM, one must be
the risk?
I have not seen this requirement. That is not to say that a
MAC carried has not provided further clarification of their
Where could we find written documentation regarding
authentication for all users? In our EMR it does not print
out on the note.
What would you recommend if the ROS/PFSH (not
You could code the E/M level based all elements of the
cloned/carried over) are complete, because the provider
history or exam, using MDM as 2 of the 3 components. So
chooses to document this way, but the HPI, CC, and MDM if MDM was SF you would level your E/M as SF.
are straightforward? Since medical necessity is overarching for most carriers, code then to the lower level?
When providers restate the complete history of a condition
and then state "today the pt. is ...", is it appropriate to use
the restating of the condition has past history and the HPI
start from the statement of Today the pt is experiencing?
If I'm understanding the question correctly, it appears that
the provider us documenting the history as the interval
history, the events between visits or leading up to this
visit. In which case, yes you could count elements for HPI.
Just use caution and never count 1 element twice.
Can providers use "10 point review of systems done"
Yes, as long as they also document the pertinent positives
or negatives for the systems related to the reason for visit.
Only stating a 10 point review of systems was done is not
The date in which the past ROS/PFSH was documented
needs to be included in the provider's note. The statement
does not necessarily need to also say "reviewed". The
statement "as before" implies the provider reviewed the
previous elements and there were not changes. Again, look
to your MAC carrier for guidance.
If the provider states ROS/PFSH "as before" (referencing
date of last encounter), do they still need to state
When providers restate the complete history of a condition Yes, you can use the elements starting from "Today the
and then state "today the pt is ...", is it appropriate to use
patient is experiencing." as HPI elements.
the restating of the condition has past history and the HPI
start from the statement of Today the pt is experiencing?
When auditing ROS and or exam elements not pertinent to
the chief complaint, how can this be supported as a valid
over documentation issue vs the physician performing
good medicine? Is it not good medicine to check heart
and lungs on all patients even if coming in for say pink eye
or sprained ankle?
As coders, we are not qualified to determine what specific
elements should or should not be documented. This is up
to the provider and his/her clinical judgment. This is an
area in which the coder/audit needs to work closely with
their providers and make a determination together.
is "all other negative" under ROS acceptable ?
Yes if the pertinent positives and negatives based on the
reason for visit are documented. Stating only "all other
negative" is not acceptable. Look for guidance from your
MAC carrier as to whether or not they allow counting
associated signs and symptoms for ROS.
If the provider states patient returned for review of
diagnostic results (labs, imaging), but no HPI, ROS, PFSH,
documented, and no exam done, do we go by time
(counseling on next steps)? or just code lowest level E&M?
This visit could be leveled using time based coding as long
as the documentation supported this. If no time is listed
then you would have to level based on the key
components. If there are not enough key components then
this visit may be support reporting an E/M.
Can elements of the HPI be pulled from other areas of the
note like the A/P? ex: HPI-breast Ca = location; A/P=Stage
II Breast Ca, ER/PR +; Can I use the stage II and ER/PR + in
the A/P for severity and quality in the HPI?
When the provider documentation includes elements of
HPI in the plan, you can count these elements for HPI
points. We can use the entire medical records for counting
E/M elements. Use caution with double dipping. For this
specific example, in my opinion, I would not consider the
description of the provider's final assessment as HPI
How do you obtain a complete HPI/ROS and PMSH on a
newborn that is 3 hours old? Mom is unavailable due to
newborn in nicu. Do you use the nurse documenation ,
may the physician document that due to the patient age
HPI/ROS unobtainable?
For RAT/STAT, OIG does extrapolation (in terms of
potential overpayment). Would you recommend doing
some type of extrapolation for internal purposes? or just
expand the audit sample?
Can the ROS/PFSH from another provider in the same
practice (most recent visit) be used if referenced? If the
doctor of one specialty references the ROS/PFSH of a
doctor in a different specialty in the same practice, it
would still count as new patient (because of different
specialty/subspecialty), regardless of the ROS reference;
If the physician is unable to obtain additional HPI/ROS
and documents why then we can count full credit for these
elements. We can use the nurse documentation for ROS
but not for HPI.
So signature log should contain signature of scribes or
other ancillary staff as well as the physicians?
My question with regard to a provider documenting
history as HPI would I use the old information as past
medical history and only the portion that is stated as
current for the HPI of that current encounter?
Yes. The signature logs should include anyone that makes
entries into the medical record.
If I understand the question correctly, you are using the old
history as Past history and using the "interval history" for
your HPI. If my understanding is correct, yes you can use
interval history for HPI point.
I would recommend just expanding your audit sample.
Expand the sample as far as you need to, to obtain a clear
understanding of the potential issue.
Yes, the provider can do this if its part of the same patient
medical record, the provider references it with the date and
if there are any updates.
can a resident be a scribe? can an APRN or PA be a scribe? Yes they can. The documentation would still need to meet
the CMS or MAC carrier scribe requirements and the claim
could not be billed under their NPI.
For new condition with work-up planned (4 points) and lab
ordered (to performed on another day) worth one data
point, do you also get 4 (new condition with lab) and 1
data point (lab ordered), or is this double-dipping on the
lab point?
Can you count past medical, family, or social history if it is
present in an electronic medical note for a specific date of
service but it is not specified that it was reviewed and
updated on that date of service?
You can count the 4 points for new problem with work and
the order/review of the lab for 1 point.
is it okay to bill an office E/M with a dialysis code?
When reporting an E/M service on the same day as a
procedure, the E/M needs to be significant and separate
from the routine or pre procedure evaluation. If not, then
reporting and E/M would not be appropriate.
No, the provide needs to reference it when collected from a
previous date of service.
So you are saying that is a provider orders lab work on one The guidelines to not specify the time in which the order or
visit and then reviews that same test on the next visit, he reviewed results can be counted. Think of it this way,
MDM is about the provider considering all diagnoses,
is given credit in both situations?
options to treat the patient and what tests to perform and
how all of these things impact the patient and their other
conditions. So if the initial decision is to order a lab, that is
1 element of MDM. Then when the lab results come back
then the provider has to make another decision on what to
do next. If that decision happens at the next visit, then you
can count it during that visit.
can an ED physician bill for their ER servcies if the patient
is admitted from the ER?m Do we change the code to
some other hospital f/u code? Thanks
If the ED provider is the one admitting the patient then no.
If the ED physician saw the patient and called in another
provider who made the decision to admit the patient then
yes. Each provider who evaluated the patient can bill for
their E/M service in most instances.
Look for guidance on acceptable E/M benchmarks from
Is there a sample of the acceptable table to have our
physicians review for E&M coding via graph or color chart? CMS and MGMA.
CPT states that the ROS should be age specific so there
How do you get a complete HPI/ROS on a 3 hour old
newborn? Is it appropriate for the physician to document may not be evidence of 10+ systems for the provider to
document on. As an auditor we need to remember the
"unable to obtain HPI due to the patient age?"
documentation for baby's and small children is different
and should be age specific.
For new condition with additional lab work-up, can you
count 4 points for the new condition and 1 for the lab in
data, if your practice does the draw on the same day, but
not the actual analysis? I know you're not supposed to
double-count the additional work-up if you actual do it
and bill for it on the same day.
In this instance I do not believe this is double counting.
Is there an industry standard on the accuracy rate that a
coder should be?
There is not an "industry standard" for accuracy of a coder.
This is something each practice needs to determine and
include as part of their compliance standards.
For moderate MDM based on prescription drugs, do they
have to the drugs prescribed by the doctor, or can it be
sufficient to score based on note of the drugs in the
medical history (so member seeing a doctor in one
specialty, taking drugs ordered by another doctor in
another specialty for a different condition)? Would the
doctor at least have to comment on how the drugs were
considered in part of the treatment being rendered?
Remember the CMS risk table state's prescription drug
management. If the provider is not managing Rx drugs
during the visit then it would not be appropriate to count
this in your MDM. What is Rx drug management? This is
another grey area. Look to your MAC carrier to see if they
have defined or define this in your practice as part of your
compliance standards.