Presented by:
Karen Kvarfordt, RHIA, CCS-P, CCDS
AHIMA Approved ICD-10-CM/PCS Trainer
President, DiagnosisPlus, Inc.
2015
 Medical
record documentation is required
to record pertinent facts, findings, and
observations about an individual’s health
history.
 Assists physicians and other health care
professionals in evaluating and planning the
patient’s immediate treatment and
monitoring his/her health over time.
“If it isn’t documented, it didn’t happen”!
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The reason the patient presented to see the
physician/provider.
Complete details of the information provided by the patient
and by the evaluation of the patient.
The results of diagnostic, consultative, and/or therapeutic
services provided to the patient.
The assessment of the patient conditions.
The plan for the care of the patient, including advice from
other physician specialists.
Other services, procedures and supplies provided to the
patient.
The time spent with the patient, if counseling or
coordinating care was provided.
3
The style and form of medical documentation
depends on the provider. However, it is important
that any reader of the medical record be able to
understand the service rendered and medical
necessity for the service.
 The medical documentation must be legible and
understandable for all providers who care for the
patient. If the handwriting of the physician
cannot be read, Medicare auditors, as well as
other payers, consider the service as not billable.

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Abbreviations or shorthand used in
documentation should be listed on an
identification key accessible to all who read the
documentation.
 All entries should be dated and signed according
to the Evaluation and Management Services
Guide published by CMS.
 It is recommended that medical documentation
be completed during or immediately following the
service provided.

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Is the reason for the patient encounter
documented in the medical record? Is the Chief
Complaint documented by the physician?
 Does the medical record clearly explain the
medical necessity of the level of E&M service,
diagnostic and therapeutic procedures, support
services and supplies provided?
 Is the assessment of the patient’s condition
apparent in the medical record?
 Medical record should tell the patient story!
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Documentation guidelines in the Evaluation and
Management Services Guide also indicate that
the documentation should be able to validate
where the services were rendered and that the
services were medically necessary and
appropriate.
 The ICD-9-CM & CPT codes reported on the
UB (facility) & 1500 (professional) should be
supported by the documentation in the medical
record.
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The history areas and medical decision making
areas frequently suffer from lack of detail. It is
common to see the words “Patient here for f/u” as
the chief complaint and the HPI. This is
insufficient as is “Patient here to establish MD.”
 With decision making, the notations “continue
present meds” and “f/u 3 months” tells nothing of
the problem(s), the status of the problem, and the
treatment or management of the problem.
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 E&M
services refer to visits and
consultations furnished by physicians and/or
providers.
 Billing for a patient visit requires the
selection of a CPT code that best represents
the level of E&M service provided. For
example, there are five (5) CPT codes that
may be selected to bill for office or other
outpatient visits for a “new” patient.
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 99201
– Usually the presenting
problem(s) are self-limited or minor and
the physician typically spends 10 minutes
face-to-face with the patient and/or
family. E&M requires the following three
key components:
 Problem focused history
 Problem focused examination
 Straightforward medical decision
making
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 99202
– Usually the presenting
problem(s) are of low to moderate
severity and the physician typically
spends 20 minutes face-to-face with the
patient and/or family. E&M requires the
following three key components:
 Expanded problem focused history
 Expanded problem examination
 Straightforward medical decision
making
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 99203
– Usually the presenting
problem(s) are of moderate severity and
the physician typically spends 30 minutes
face-to-face with the patient and/or
family. E&M requires the following three
key components:
 Detailed history
 Detailed examination
 Medical decision making of low
complexity
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 99204
– Usually the presenting
problem(s) are of moderate to high
severity and the physician typically
spends 45 minutes face-to-face with the
patient and/or family. E&M requires the
following three key components:
 Comprehensive history
 Comprehensive examination
 Medical decision making of moderate
complexity
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 99205
– Usually the presenting
problem(s) are of moderate to high
severity and the physician typically
spends 60 minutes face-to-face with the
patient and/or family. E&M requires the
following three key components:
 Comprehensive history
 Comprehensive examination
 Medical decision making of high
complexity
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To determine the appropriate level of service
for a patient's visit, it is necessary to first
determine whether the patient is ‘new’ or
already ‘established’.
 CPT 2012 Revised Definitions:
 New - “A new patient is one who has not
received any professional services from the
physician or another physician of the exact
same specialty and subspecialty who belong to
the same group practice within the past
three years”.
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 Established
– “An established patient
is one who has received professional
services from the physician or another
physician of the exact same specialty
and subspecialty who belongs to the
same group practice within the past
three years”.
 Exception! Patients seen in the
Emergency Room do not have the
distinction of ‘new’ vs. ‘established’.
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 ER
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99821
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Problem focused history & examination
Straightforward MDM
Usually presenting problem(s) are self limited or minor.
99282
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providers use following CPT codes:
Expanded problem focused history & examination
Low complexity MDM
Usually presenting problem(s) are of low to moderate
complexity
99283
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Expanded problem focused history & examination
Moderate complexity MDM
Presenting problem(s) are of moderate severity
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 99284
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Detailed history and examination
MDM of moderate complexity
Usually the presenting problem(s) are of high
severity, and require urgent eval by the
physician but do not pose an immediate
significant threat to life/physiological function
 99285
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Comprehensive history & exam and MDM of high
complexity
High severity and pose an immediate significant
threat to life/physiological function
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1995
Documentation Guidelines
 General multi-system exam (7
body areas or 12 body systems)
 Problem Focused = 1
 Expanded Problem Focused = 2-4
 Detailed = 5-7
 Comprehensive = 8 or more
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 1997
Documentation Guidelines
 Multi-system exam or one of ten
individualized single system exams
 Get ‘credit’ for documentation of 3 or
more chronic conditions
 History and Medical Decision Making are
the same for 1995 & 1997
 CMS – Use whichever set of results is
most in the physicians’ favor.

However, you can’t mix & match!
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 The
three key components of E&M
services are:
 History
 Physical Examination
 Medical Decision Making

Please note that just because the E&M level is dependent on
two or three key components, performance & documentation
of one component, ie, examination, at the highest level does
not necessarily mean that the encounter in its entirety
qualifies for the highest level of E&M.
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 Chief
Complaint – Each note must always include
a chief complaint even if the chief complaint
describes that the patient is presenting for
follow-up of a previous problem, the reason for
the visit must be clear as in “Patient presenting
for f/u of uncontrolled hypertension.”
 Usually stated in the patient’s own words.
 Sometimes referred to as “presenting
problem.”
 Example: Patient complains of upset stomach,
aching joints, or fever.
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 Information
that is given by the patient
to the physician
 The history consists of 3 parts
 History of Present Illness (HPI)
 Review of Systems (ROS)
 Past, Family, Social History (PFSH)
 Remember!
The Chief Complaint and
the HPI must be documented by the
physician.
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TYPE OF
HISTORY
CHIEF
COMPLAINT
HISTORY OF
PRESENT
ILLNESS
REVIEW OF
SYSTEMS
PAST, FAMILY,
AND/OR SOCIAL
HISTORY
Problem
Focused
Required
Brief
N/A
N/A
Expanded
Problem
Focused
Required
Brief
Problem
Pertinent
N/A
Detailed
Required
Extended
Extended
Pertinent
Comprehensive
Required
Extended
Complete
Complete
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History of Present Illness – Includes information described by the
patient about the current condition including:
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Location – refers to the location of the problem/symptoms – left lower
quadrant; left leg; right arm; etc.
Severity – severity of the presenting problem – mild, severe; increasing;
resolving, etc.
Timing – the interval of the pain or suffering – every night; constant; comes and
goes; intermittent, etc.
Modifying Factors – how is the pain symptom modified – relieved by standing
erect; better after taking aspirin; walking makes pain worse; etc.
Quality – descriptive adjective – dull; sharp; aching; stinging; throbbing, etc.
Duration – how long the patient has had the symptoms – two days; since last
visit; since this morning, etc.
Context – describes how the symptoms began or occurred – after the auto
accident; after eating out at a restaurant; when I sit down; etc.
Associated Signs and Symptoms – these are significant signs/symptoms that
the patient feels are related to/part of their injury or illness – dizziness with
nausea; swelling with injury; double vision with headache, etc.
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Alternate HPI
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Documentation of three chronic illnesses
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Must be related to chief complaint
Status of each condition must be documented
Example
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Chief Complaint (CC)
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Follow-up of HTN & Lower Extremity Edema
HPI –
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(1) Patient states that home BP readings have been 130/80 –
145/85 with Diovan. (2) Patient states legs are not as swollen
at end of day. (3) She states that headaches are less
frequent and severe. (4) She has also been able to lose some
weight and has more energy.
Brief HPI consists of 1 to 3 elements of the HPI
 Extended HPI consists of at least 4 elements of
the HPI or the status of at least 3 chronic or
inactive conditions
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Review of Systems – Includes the patient’s “inventory” of signs and/or
symptoms. These are most often answers to questions asked by the
provider in order to establish a working diagnosis. Systems are:
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Constitutional – weight loss, fever, chills, malaise, etc.
Ear, nose throat, and mouth – hearing loss, sinusitis, sore throat, oral cavities,
etc.
Gastrointestinal – nausea, vomiting, diarrhea, constipation, ulcer, etc.
Integumentary – skin rashes, moles, dryness, lumps, pigmentation, etc.
Endocrine – polyuria, polydipsia, cold-heat intolerance, diabetes, etc.
Genitourinary – hematuria, nocturia, menopause, incontinence, etc.
Hematologic/Lymphatic – anemia, bruising, bleeding, lymph node enlargement, etc.
Eyes – diplopia, blurred vision, glasses, etc.
Cardiovascular – chest pain or pressure, palpitations, murmur, hypertension, etc.
Musculoskeletal – arthritis, joint stiffness, swelling, myalgias, gout, etc.
Neurologic – dizziness, syncope, seizures, vertigo, weakness, tremor, etc.
Allergic/Immunologic – allergies to medicine, food, etc./hepatitis, HIV, etc.
Respiratory – cough, wheezing, asthma, etc.
Psychiatric – depression, agitation, panic-anxiety, memory disturbance, etc.
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
The Review of Systems should be pertinent to the
presenting problem – All pertinent positive and negatives
should be documented. If all systems are reviewed, after
the pertinent systems are documented, the statement “all
other systems have been reviewed and are negative” will
be appropriate for a complete review of systems.
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If a separate form is used for the Review of Systems, it should
be dated and initialed by the provider with pertinent comments
noted. This can be referred to by documenting “Review of
Systems as noted on face sheet dated __ __ ____ has been
reviewed with the following changes”.
But be careful in using this statement! It is not necessary
to have a complete ROS for a minor problem such as a
sprained ankle or sinusitis. Right?
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 Problem
Pertinent
 Inquiries about the system directly
related to the problem identified in the
HPI.
 The patient’s positive responses and
pertinent negatives for the system
related to the problem should be
documented
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In the following example, one system – the
ear- is reviewed:
Chief Complaint: Earache
 ROS: Positive for left ear pain. Denies dizziness,
tinnitus, fullness or headache
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Extended/Expanded Problem
 Inquiries about the system directly related to
the problem(s) identified in the HPI and a limited
number (two to nine) of additional systems.
 Patient’s positive responses and pertinent
negatives for two to nine systems should be
documented.

In the following example, two systems –
cardiovascular and respiratory- are reviewed:
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Chief Complaint: Follow-up visit in office after cardiac
cath. Patient states “I feel great.”
ROS: Patient states he feels great and denies chest pain,
syncope, palpitations, and shortness of breath. Relates
occasional unilateral, asymptomatic edema of the left leg.
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 Complete
Inquiries about the system(s) directly related to the problem(s)
identified in the HPI plus all additional (minimum of 10) body
systems.
 At least 10 organ systems must be reviewed with positive systems
or pertinent negative responses must be individually documented.
For the remaining systems, a notation indicating “all other systems
are negative” is permissible.
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In the following example, 10 signs & symptoms are reviewed:

Chief Complaint: Patient complains of “fainting spell.”
ROS:
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Constitutional: weight stable, + fatigue
Eyes: + loss of peripheral vision
Ear, Nose, Mouth, Throat: no complaints
Cardiovascular: + palpitations; denies chest pain, calf pain, pressure or edema
Respiratory: + shortness of breath on exertion
Gastrointestinal: appetite good, denies heartburn, + episodes of nausea
Urinary: denies incontinence, frequency, urgency, nocturia
Skin: + clammy, moist skin
Neurological: + fainting; denies numbness, tingling and/or tremors

Psychiatric: denies memory loss or depression. Mood pleasant.

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
Past, Family & Social History
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May also be documented by “Refer to history on face
sheet dated __ __ ____ with the following changes:”
Past Medical History – includes adult & childhood
illnesses or trauma, vaccinations & screenings, past
surgical history, past & current medications, allergies.
Family History – includes parents, siblings, children,
genetic disease of the family or other family history.
Social History – Information about the patient’s habits
and circumstances – smoking, alcohol, drug use; sexual
orientation, marital status, living arrangements,
occupation, education, religion, recent travel.
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 History
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is unobtainable:
Patient is unconscious, mentally ill, unable to
speak, intoxicated, intubated
No other source is available
 Document
the reason why the patient is
unable to communicate and also that no
other source is available, if applicable.
 Physician is given credit for PFSH if unable
to obtain from the patient.
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 Key
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Components of Physical Exam
Should be pertinent to the presenting problem,
i.e. if an established patient is in for follow-up of
allergic rhinitis, a head to toe exam is not
necessary.
Should never, ever be copied forward from a
previous visit.
Care should be taken when using a check off form
with “Normal” – not just go down the line √ off
systems!
Some auditors consider “WNL” as “We Never
Looked.
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TYPE OF EXAMINATION
DESCRIPTION
Problem Focused
Include performance and documentation of 1-5 elements
identified by a bullet in 1 or more organ system(s) or body area(s).
Expanded Problem Focused
Include performance and documentation of at least 6 elements
identified by a bullet in 1 or more organ system(s) or body area(s).
Detailed
Include at least 6 organ systems or body areas. For each
system/area selected, performance & documentation of at least 2
elements identified by a bullet is expected. May include
performance & documentaiton of at least 12 elements identified
by a bullet in 2 or more organ systems or body areas.
Comprehensive
1997: Include at least 9 organ systems or body areas. For each
system/area selected, all elements of the examination identified
by a bullet should be performed, unless specific directions limit
the content of the examination. For each area/system,
documentation of at least 2 elements identified by bullet is
expected.
1995: 8 organ systems must be examined. If body areas are
examines and counted, they must be over and above the 8 organ
systems.
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
The 10 single organ system examinations are:
 Cardiovascular
 Ear, Nose, Mouth and Throat
 Eyes
 Genitourinary (male & female)
 Hematologic/Lymphatic/Immunologic
 Musculoskeletal
 Neurological
 Psychiatric
 Respiratory
 Skin
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 Specific
abnormal and relevant negative
findings of the exam of the affected or
symptomatic body area(s) or organ system(s)
should be documented.
 A notation of “abnormal” without elaboration
is insufficient.
 Brief statement or notation indicating
‘negative’ or ‘normal’ is sufficient to
document normal findings related to
unaffected area(s) or asymptomatic organ
system(s).
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 Number
options:
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of diagnosis(es) or management
All known diagnoses that are being treated or
affect treatment
Undiagnosed conditions that are being evaluated
Treatments being used, considered or planned
Plays the ‘primary’ role in determining the correct
level of service
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If a diagnostic service is ordered, planned,
scheduled or performed at the time of the E&M
visit, the type of service should be documented.
 Review of labs or any diagnostic tests should be
documented.
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
“WBC elevated” or “chest x-ray unremarkable” is
acceptable. The review may be documented by initialing
& dating the report that contains the test results.
Decision to obtain medical records or history from
someone other than the patient must be
documented.

“Old records reviewed” or “additional history obtained
from the family” without further elaboration is not
sufficient – no credit should be given.
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 Risk
of significant complications,
morbidity, and mortality is based on the
risks associated with:
 Presenting problem(s) or number of
diagnoses and/or risk of complications
(Chief Complaint)
 Diagnostic procedures ordered
 Possible management options
 Table
of Risk
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Used in selecting an E&M code only when
Counseling and/or Coordination of care
represents more than 50% of the time spent
face-to-face (outpatient) or bedside and on the
floor or unit with the patient or family
(inpatient).
 Both time elements – total length of time for
the visit and total length of time involved in
Counseling and/or Coordination of care – as well
as the nature of the counseling and/or
coordination of care must be documented
explicitly in the medical record.

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 (S)ubjective

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Chief Complaint – Each note must always
include a chief complaint.
History of Present Illness
Review of Systems
Past Medical, Family and Social History
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 Physical
Examination – the second of the
three key components for evaluation and
management is documented by the provider.
 Amount and Complexity of Data

Review of tests, records, independent review
of tracings, specimens, etc.
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 Number
of diagnoses: The following should
be considered:


All known diagnoses that are being treated or
affect treatment
Undiagnosed conditions that are being evaluated
 Risk
of complications and/or morbidity or
mortality
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
Treatment Options:
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Prescription drug management
Diagnostic tests
IV Fluids
Surgeries
Decision not to resuscitate
Return to Office
Referral to another physician
Physical, Occupational, Speech Therapy
Over the Counter Drugs
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 CPT
codes 99354-99357 are used when a
physician provides prolonged services
involving direct (face-to-face) patient
contact beyond the usual service in either
the inpatient or outpatient setting.
 Reported in addition to E&M level.
 Report the total duration of the face-toface time spent even if not continuous.
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 Bill
the first hour with CPT 99354, 99356
 Each additional 30 minutes with CPT 99355,
99357
 Can only be reported ‘once’ per day
 Less than 30 minutes is included in the E&M
level

Example:

Physician performed a visit that met the definition of
visit code 99213 & the total duration of the direct
face-to-face services (including the visit) was 65
minutes.
 Physician bills E&M 99213 and 1 unit of CPT 99354.
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 Initial



Hospital Care
99221 (low severity – 30 minutes)
99222 (moderate severity – 50 minutes)
99223 (high severity – 70 minutes)
 Subsequent



Hospital Care
99231 (Stable, recovering or improving – 15
minutes at bedside)
99232 (Responding inadequately/developed
minor complication – 25 min)
99233 (Unstable/developed significant
complication or new problem – 35 min)
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 Documentation
does not always include the
total time spent performing the discharge
day management function


Review of the medical record
Completion of discharge summary
 99238

Less than 30 minutes
 99239

More than 30 minutes
 CPT

Default:
If time is not documented, then the lesser of
the two is billed, i.e., 99238.
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 Requires
‘direct personal management’ from
a physician, the absence of which ‘would
likely result in sudden, clinically significant
or life-threatening deterioration’ of the
patient.
 Examples:
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Acute allergic reaction(s)
GI bleed
Subdural/subarachnoid hemorrhage
AMI
Respiratory distress/failure
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 Critical
Care is a ‘time’ driven CPT code.
 Does not require constant bedside attendance.


Reviewing ancillary studies
Discussions with nursing staff, physicians, family
members & documentation of these interventions in
the medical record
 Billable

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procedure include (but not limited to):
Endotracheal intubation
CPR
Chest tube placement
CVP line insertions
EKG interpretation
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 Physician(s)
MUST document critical care
for the encounter in the record.
 State the time spent providing critical care
in minutes:


99291 = 30-74 documented minutes
99292 = Each additional 30+ documented
minutes
 The
HPI & ROS guidelines are not required
for Critical Care, however, documentation
does need to support medical necessity for
the high level of service.
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If it is NOT documented,
it did NOT happen!
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Karen Kvarfordt, RHIA, CCS-P, CCDS
AHIMA Approved ICD-10-CM/PCS Trainer
President, DiagnosisPlus, Inc.
PO Box 486
Pocatello, ID 83294
(208) 221-5486
Fax: (360) 234-7590
diagnosisplus1@live.com
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