A Minute for the Medical Staff
A supplement to medical records
briefing
February 1999
Know the E&M documentation guidelines
and prevent a loss in revenue
By Thomas Sills, MD
Chief Financial Resource, Inc.
Evaluation and management (E&M) coding – the way
in which medical practices are paid for most E&M
services – is a problem for many physicians because
documenting these services is confusing and
complicated.
However, since undercoding leads to a loss in revenue
and overcoding puts you at risk for a fraud and abuse
investigation, it’s critical that you code these services
properly. Unfortunately there are a lot of grey areas
with E&M coding, especially when it comes to which
documentation guidelines to use.
Currently, physicians may use either the American
Medical Association’s (AMA) 1995 or 1997
guidelines. In the spring, the AMA hopes to pilot test
a brand new set of guidelines, which it claims will be
simpler to follow. It’s unclear when these new
guidelines will actually go into effect or how
simplified they will be, however.
What you should do now
Until the new guidelines come out, you should choose
either the AMA’s 1995 or 1997 guidelines to follow
and ensure that either you or your staff know how to
apply them correctly. According to both sets of rules,
coding (and payment) is based only on what you
document. For coding and billing purposes, if it isn’t
documented, then it didn’t happen. Obviously, you
only document what you do, and only do what is
medically necessary.
By knowing the coding rules, you can efficiently
document the data that you are actually gathering to
allow for complete and accurate coding (and billing.)
Documentation tips
E&M coding guidelines are primarily based on three
components: history, physical exam, and medical
decision-making.
History
Physicians usually find history the most difficult to
document, which sometimes prevents the assignment
of the appropriate E&M level.
HPI: There are two levels of HPI, brief and extended.
Brief has one to three elements and extended has four
or more. The elements are specifically defines as
severity, duration, timing, context, modifying factors
and associated signs and symptoms. For average to
complex cases, document four or more elements of the
HPI.
ROS: Any case except the most simple should have at
least one symptom reviewed and documented.
Comprehensive evaluations require 10 or more
systems or the specific statement that “all other
systems were negative.”
PFHSx: In all except the most complicated cases,
document one of these three elements (past, family or
social hx). In comprehensive cases, document all
three.
For patients who can not give a history, document
“Patient unable to give history.”
Physical exam
Based on both the AMA’s guidelines in place since
1995, all but the most minor cases need documentation
of more than one body system or area examined.
Comprehensive exams need eight or more systems or
body areas examined. The exams are defined as
* Constitutional
* chest / breast
* respiratory
* ENT
* Neurologic
* GU
* Skin
* cardiovascular
* eyes
* psychiatric
* GI
* neck
* lymphatic
* musculoskeletal
Medical decision-making
The coding rules for medical decision-making are the
least explicit. Document the following when feasible
for full and accurate coding:
 Diagnosis or assessment (including differential
diagnosis)
 Treatment
 Tests ordered
 Additional history from family
 Referrals to other physicians
 Test results
 Reviews of old records
 Procedures
Example of proper and improper documentation of
one E&M coding case
The following office record entry is poorly
documented from a coding perspective.
A 66 y/o female presents with a complaint of D.O.E.
for 4 months. She denies chest pain or other
symptoms. She denies cough, sputum production,
abdominal pain, melatonic stools, change in bowel
habits, ankle edema, or claudication of the legs. Pt. is
on no meds and past hx is positive for appendectomy
and cholecystecotmy years ago. She has a 40-pack-ayear history of smoking and quit 2 years ago.
NAD P78, R 16, BP 140/90
neck-no bruits
HEENT - unremarkable Cor-RRR, II/VI SEM at
Lungs - clear to A and P LSB 4th ICS
Abd - soft, non tender
Neuro - motor, sensory, CN intact
Ext – no edema
Imp: D.O.E., ? etiology
Plan: CXR, EKG, cbc, lytes, thyroid panel, chem
profile. Follow up in 5 days.
This visit would be coded to 99202 – new patient level
2. Compare this to the following entry which is
effectively documented for the exact same visit which
now can be coded to 99204 – new patient level 4.
A 66 y/o female presents as a new patient with
moderate D.O.E. for 4 months, brought on by walking
over 100 feet, resolving after 2 minutes rest. No
current meds.
Past Hx – Appy and cholecystectomy 1960s
Soc. Hx – 40 pk-yrs, quit 2 years ago
Fm Hx – neg for heart disease
ROS – no weight change, visual disturbance + chronic
sore throat and slight sputum production; no melena,
dysuria, ankle edema, joint pain, rashes, syncope
NAD P78, R16, BP 140/90 skin – no rashes or lesions
HEENT–PERRL, EOM intact: pharynx red, no masses
Neck – no bruits
lungs – clear to A and P
Cor – RRR, II/VI SEM
Abd – no masses, guiac neg
stool: Ext – no edema, full ROM bilateral: Neurooriented x 3, CN intact
Imp: D.O.E., ? etiology
Plan: CXR, EKG, cbc, lytes, thyroid panel, chem
profile. Follow up in 5 days.
The difference between the two entries are the second
entry has
a. four-plus elements of the HPI, the first only has
three
b. past medical, family, and social hx documented
c. 10 systems in the ROS
d. more than eight systems documented as examined
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