E&M AUDITING
Clarifying
Requirem ents
And Providing
Tools For
Success
Speaker: Marisa
Clauson, CPC
DOCUMENTATION REQUIREMENTS
 The first step in understanding medical record
documentation is becoming knowledgeable of the
Evaluation and Management guidelines by which
Physicians and Advanced Practice Professionals
must document their services.
MEDICAL NECESSIT Y
“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. 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.”
Per Internet Only Manual (IOM) Medicare Claims Processing
Manual, Publication 100-04, Chapter 12, section 30.6.1
GENERAL PRINCIPLES
The record should be complete and legible.
Each documented encounter should include:
• The reason for the encounter, relevant history, physical exam findings and prior diagnostic
test results.
• The plan of care
• Date and legible identify of the provider
• If not specifically documented, the rationale for ordering diagnostic and other ancillary
services should be easily inferred.
• Past and present diagnosis should be accessible
• Appropriate risk factors should be identified.
• The patient’s progress, response to and changes in treatment should be documented.
CLONED DOCUMENTATION IS
INAPPROPRIATE
Centers for Medicare & Medicaid Services (CMS) contractors
have been monitoring supporting documentation of E/M
services, and have noticed among EHR users a high volume
of records with identical documentation across services. In
other words, information from previous encounters is
brought forward without updating, which brings into
question the validity of the entire service.
CLONED DOCUMENTATION-CONTD.
Medicare contractors consider records cloned when:
 Each entry in medical record is worded exactly like or similar
to the previous entries.
 Medical documentation is exactly the same from patient to
patient.
 Cloning often occurs on claims for procedures that have
specific sets of coverage criteria and is most often found as
pre-printed, template-type and/or electronic health record
notes.
 Medicare contractor position: “Cloning of documentation will
be considered misrepresentation of the medical necessity
requirement for coverage of services”.
 What makes this visit dif ferent/medically necessary from the
previous visit, when both are recorded exactly the same?
1995 VS. 1997 DOCUMENTATION
GUIDELINES
 Many providers feel that the 1995 guidelines meet their needs
more ef fectively as the documentation requirements aren’t as
cumbersome and specific. That being said, the documentation
will be less detailed then if the provider were using the 1997
guidelines.
 Providers can choose to use either the 1997 or the 1995
guidelines, whichever is more advantageous to the provider.
 It's hard to say that one set of rules is "better" because each
version has advantages and disadvantages. You must choose to
use one or the other. It is NOT ACCEPTABLE to mix and match
elements from both sets of rules within the same note.
EVALUATION & MANAGEMENT SERVICES
The level of service billed is based on the following three key
elements:
 History
 Exam
 Medical Decision Making
Other contributory components would be:




Counseling
Coordination of care (with other providers)
Nature of presenting problem
Time (must be documented in record if used for level of service)
HISTORY: CHIEF COMPLAINT
 Every medical record must document a chief complaint
(reason for visit).
 Usually stated in the patients words
 Example: Four year old boy complaining of bilateral ear pain,
sore throat and fever.
 Any note not containing a chief complaint will not meet any
level of History as it is required for all E&M service levels.
 The chief complaint does not have to be separately
documented from the HPI.
CHIEF COMPLAINT
If the visit is strictly for follow up,
the condition being followed
must be documented.
Inappropriate example: Patient
here for follow up
Appropriate Example: Patient is
here for follow up regarding
diabetes management.
HISTORY OF PRESENT ILLNESS (HPI)
 The HPI describes the patients current illness from the first
sign and/or symptom to present or from the previous
encounter to the present.
 The HPI must be documented by the provider.
 There are a total of 8 elements that can be used to describe
the HPI.
 Ef fective Sept. 30, 2013, when billing Medicare, you may
combine the 1997 extended HPI elements along with the
1995 exam guidelines. (Status of 3 or more chronic
conditions)
HPI ELEMENTS
Location- Where the
symptom is
occurring
Modifying FactorsActions done to
make symptom
better or worse
Context- Instances
that can be
associated with
the symptom.
Timing- When the
symptom occurs
Quality- Describing
the symptom or
pain
Severity- Rating or
describing the
symptom or pain
Duration- How long
has the pain or
symptom been
present
HPI ELEMENTS, CONT.
There are two levels of HPI:
•Brief ( 1 to 3 elements)
•Extended (4 or more elements)
Example: Patient complaining of left knee (location) pain for three days
(duration).
Example: Patient complaining of sharp (quality) left knee (location) pain for
three days (duration), worsens with weight bearing (context).
REVIEW OF SYSTEMS (ROS)
Positive or negative responses to questions that are asked of the
patient.
The ROS can be documented by the patient on a questionnaire or
by medical staf f.
If the provider references this document, he/she would need to
document it in the medical record. The provider would also
need to date and sign the document to show that it was
referenced.
REVIEW OF SYSTEMS
A total of 14 systems
1)
2)
3)
4)
5)
6)
Constitutional Symptoms (usual weight, recent weight changes,
fever, weakness, fatigue)
Eyes (Visual disturbance, glaucoma, cataracts, pain, redness)
Ears, Nose, Mouth, Throat (Hearing, discharge, tinnitus,
dizziness, pain, head cold, soreness, redness, hoarseness,
difficulty swallowing)
Cardiovascular (Chest pain, rheumatic fever, tachycardia,
palpitation, elevated blood pressure, edema, faintness,
varicose veins)
Respiratory (Chest pain, wheezing, cough, dyspnea, bronchitis)
Gastrointestinal (Appetite, thirst, nausea,, hematemesis, rectal
bleeding, diarrhea, constipation)
REVIEW OF SYSTEMS (CONT.)
7)
8)
9)
10)
11)
12)
13)
14)
Genitourinary (Urinary Frequency, pain, nocturia, hematuria,
incontinence, menstruation changes, symptoms of menopause)
Musculoskeletal (Joint of muscle pain, stiffness, cramps,
swelling, limitation in motor activity)
Integumentary (Rashes, eruptions, dryness, jaundice, changes
in skin, hair or nails)
Neurological (Headaches, faintness, blackouts, seizures,
tingling, tremors, memory loss, involuntary movements)
Psychiatric (Personality type, nervousness, mood, insomnia,
nightmares, depression)
Endocrine (Thyroid trouble, heat or cold intolerance, excessive
sweating, thirst, hunger or urination)
Hematologic/Lymphatic (Anemia, easy bruising or bleeding,
jaundice, transfusions)
Allergy/Immunologic (Difficulty breathing, anaphylaxis,
swelling, sneezing, runny nose or itchy eyes in response to
food, medication or airborne allergens)
THREE LEVELS OF
REVIEW OF SYSTEMS
Problem Pertinent
(Inquires about the
system directly
related to the
problem identified in
the HPI) - 1 system
Extended (Inquires
about the system
directly related to the
problem identified in
the HPI and a limited
number of additional
systems) – 2 to 9
systems
Complete (Inquires
about the system
directly related to the
problem(s) identified
in the HPI plus ALL
additional body
systems) 10+
systems
PFSH - PAST, FAMILY & SOCIAL HISTORY
Past Medical History: Current medications, Prior illness/injuries,
Operations & hospitalizations, Allergies or Age appropriate vaccinations.
Family History: Health status or cause of death related to parents, siblings
and children. Diseases related to chief complaint, HPI or ROS; Hereditary
or high risk diseases.
Social History: Living arrangements, Marital Status, Sexual history, use of
drugs, alcohol or tobacco. Extent of education; Current employment.
WHAT IS YOUR HISTORY LEVEL?
History Type
Chief Complaint
HPI
ROS
PFSH
Problem Focused
Chief Complaint
Brief (1-3)
None
None
Expanded Problem Chief Complaint
Focused
Brief (1-3)
Problem
Pertinent
None
Detailed
Chief Complaint
4+
2-9
Pertinent (1)
Comprehensive
Chief Complaint
4+
Complete
(10+)
Complete (3)
Est. (2)
All three elements in the table must be met to qualify for a given type of history.
DO NOT count a given element more than once in determining a type of history. For example,
an element counted in the HPI may not be counted again as an element of the ROS.
Review of system MUST be medically necessary for chief complaint. If patient presents for a
ankle sprain you should not be checking the Genitourinary system!
WHAT LEVEL OF HISTORY IS THIS??
10 year old boy presents today complaining of right wrist pain.
He indicates that he was skate boarding yesterday and fell.
Feels sharp pain when he grabs at objects. Mom indicates that
Tylenol does seem to help a little.
Review of system: Patient states wrist hurts with movement.
No PFSH documented.
CODE MY LEVEL OF HISTORY….
1.
2.
3.
4.
4 HPI Documented
Location- Right Wrist pain
Duration- Fell yesterday
Quality - Sharp pain
Modifying Factors- Tylenol helps a little
1 Review of Systems
1. Musculoskeletal
No Past, Family or Social History
History= Expanded Problem Focused
EXAM SYSTEMS
1) Constitutional (Vital signs, general appearance)
2) Eyes
3) Ears, nose throat & mouth ( When auditing, verify all 3 areas
are documented to give credit)
4) Cardiovascular
5) Respiratory
6) Gastrointestinal
7) Genitourinary
8) Musculoskeletal
9) Skin
10) Neurologic
11) Psychiatric
12) Hematologic, lymphatic, immunologic
LEVELS OF E&M SERVICES
Based on four types of exams, using 1995 Guidelines
1) Problem Focused- A limited examination of the af fected
body area or organ system
2) Expanded Problem Focused- A limited examination of the
af fected body area or organ system and other symptomatic
or related organ system(s)
3) Detailed- An extended examination of the af fected body(s)
and other symptomatic or related organ system(s)
4) Comprehensive- A general multi-System examination or
complete examination of a single organ system(s)
EXAMINATION
 An examination may involve several organ systems or a single
organ system. The type and extent of the examination
performed is based upon clinical judgment, the patient’s
history, and nature of the presenting problem(s).
 The 1995 documentation guidelines describe two types of
comprehensive examinations that can be performed during a
patient’s visit: general multi -system examination and single
organ examination.
 1997 Guidelines - A general multi-system examination
involves the examination of one or more organ systems or
body areas, as depicted in the chart on the next slide.
TYPE OF EXAMINATION
DESCRIPTION
Problem Focused
Include performance and documentation of one to five
elements identified by a bullet in one or more organ
system(s) or body area(s).
Expanded Problem Focused
Include performance and documentation of at least six
elements identified by a bullet in one or more organ
system(s) or body area(s).
Detailed
Include at least six organ systems or body areas. For
each system/area selected, performance and
documentation of at least two elements identified by a
bullet is expected. Alternatively, may include
performance and documentation of at least twelve
elements identified by a bullet in two or more organ
systems or body areas.
Comprehensive
Include at least eight 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 two elements identified by bullet is expected.*
1997 Guidelines:
A single organ system examination involves a more extensive
examination of a specific organ system, as depicted in the
chart below
A single organ system examination involves a more extensive
Type
of Examination
Description
examination
of a specific
organ system, as depicted in the chart
below.
Problem
Focused
Include performance and documentation of one to five elements
identified by a bullet, whether in a box with a shaded or unshaded
border
Expanded Problem Focused
Include performance and documentation of at least six elements
identified by a bullet, whether in a box with a shaded or unshaded
border.
Detailed
Examinations other than the eye and psychiatric examinations
should include performance and documentation of at least twelve
elements identified by a bullet, whether in a box with a shaded or
unshaded border.
Eye and psychiatric examinations include the performance and
documentation of at least nine elements identified by a bullet,
whether in a box with a shaded or unshaded border
Comprehensive
Include performance of all elements identified by a bullet,
whether in a shaded or unshaded box.
Documentation of every element in each box with a shaded
border and at least one element in a box with an unshaded border
is expected
WHAT LEVEL IS YOUR EXAM?
Some important
points that should
be kept in mind
when documenting
general multisystem and single
organ system
examinations (in
both the 1995 and
the 1997
documentation
guidelines) are:
•Specific abnormal and relevant negative findings
of the examination of the affected or
symptomatic body area(s) or organ system(s)
should be documented. A notation of “abnormal”
without elaboration is not sufficient.
•Abnormal or unexpected findings of the
examination of any asymptomatic body area(s) or
organ system(s) should be described.
•A brief statement or notation indicating
“negative” or “normal” is sufficient to document
normal findings related to unaffected area(s) or
asymptomatic organ system(s).
COUNSELING
Documentation of an Encounter Dominated by Counseling and/or
Coordination of Care
 When counseling and/or coordination of care dominates (more
than 50 percent of) the physician/patient and/or family
encounter (face-to-face time in the office or other outpatient
setting, floor/unit time in the hospital, or NF), time is considered
the key or controlling factor to qualify for a particular level of
E/M services. If the level of service is reported based on
counseling and/or coordination of care, the total length of time
of the encounter should be documented and the record should
describe the counseling and/or activities to coordinate care.
 The Level I and Level II CPT® books, which are available from
the American Medical Association, list average time guidelines
for a variety of E/M services. These times include work done
before, during, and after the encounter. The specific times
expressed in the code descriptors are averages and, therefore,
represent a range of times that may be higher or lower
depending on actual clinical circumstances.
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:
 The number of possible diagnoses and/or the number of
management options that must be considered;
 The amount and/or complexity of medical records, diagnostic
tests, and/or other information that must be obtained,
reviewed, and analyzed; and
 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.
The chart below depicts the elements for each level of medical
decision making. To qualify for a given type of medical decision
making, two of the three elements must either be met or
exceeded.
TYPE OF
DECISION
MAKING
# OF DIAGNOSIS
AMOUNT AND/ OR
OR MANAGEMENT COMPLEXITY OF
OPTIONS
DATA TO BE
REVIEWED
RISK OF SIGNIFICANT
COMPLICATIONS,
MORBIDITY, AND/OR
MORTALITY
Straightforward
Minimal
Minimal or None
Minimal
Low Complexity
Limited
Limited
Low
Moderate
Complexity
Multiple
Multiple
Moderate
High Complexity
Extensive
Extensive
High
NUMBER OF DIAGNOSES AND/OR
MANAGEMENT OPTIONS
The number of possible diagnoses and/or the number of
management options that must be considered is based on:
 The number and types of problems addressed during the
encounter;
 The complexity of establishing a diagnosis; and
 The management decisions that are made by the physician
In general, decision making with respect to a diagnosed problem is
easier than that for an identified but undiagnosed problem. The
number and type of diagnosed tests performed may be an indicator
of the number of possible diagnoses. Problems that are improving
or resolving are less complex than those problems that are
worsening or failing to change as expected. Another indicator of
the complexity of diagnostic or management problems is the need
to seek advice from other health care professionals.
IMPORTANT POINTS TO REMEMBER
• For each encounter, an assessment, clinical impression, or diagnosis should be
documented which may be explicitly stated or implied in documented decisions
regarding management plans and/or further evaluation:
• For a presenting problem with an established diagnosis, the record should reflect
whether the problem is:
• - Improved, well controlled, resolving, or resolved; or
• - Inadequately controlled, worsening, or failing to change as expected.
• For a presenting problem without an established diagnosis, the assessment or
clinical impression may be stated in the form of differential diagnoses or as a
“possible,” “probable,” or “rule out” diagnosis.
• The initiation of, or changes in, treatment should be documented. Treatment
includes a wide range of management options including patient instructions, nursing
instructions, therapies, and medications.
• If referrals are made, consultations requested, or advice sought, the record should
indicate to whom or where the referral or consultation is made or from whom advice
is requested
AMOUNT AND/OR COMPLEXIT Y OF DATA TO
BE REVIEWED
The amount and/or complexity of data to be reviewed is based
on the types of diagnostic testing ordered or reviewed.
Indications of the amount and/or complexity of data being
reviewed include:
 A decision to obtain and review old medical records and/or
obtain history from sources other than the patient (increases
the amount and complexity of data to be reviewed);
 Discussion of contradictory or unexpected test results with
the physician who performed or interpreted the test (indicates
the complexity of data to be reviewed); and
 The physician who ordered a test personally reviews the
image, tracing, or specimen to supplement information from
the physician who prepared the test report or interpretation
(indicates the complexity of data to be reviewed).
Some important points that should be kept in mind when
documenting amount and/or complexity of data to be
reviewed include:
•If a diagnostic service is ordered, planned, scheduled, or
performed at the time of the E/M encounter, the type of
service should be documented.
•The review of laboratory, radiology, and/or other diagnostic
tests should be documented. A simple notation such as
“WBC elevated” or “Chest x-ray unremarkable” is
acceptable. The review may alternatively be documented
by initialing and dating the report that contains the test
results.
•A decision to obtain old records or obtain additional history
from the family, caretaker, or other source to supplement
information obtained from the patient should be
documented.
COMPLEXIT Y OF DATA, CONT.
 Relevant findings from the review of old records and/or the
receipt of additional history from the family, caretaker, or
other source to supplement information obtained from the
patient should be documented. If there is no relevant
information beyond that already obtained, this fact should be
documented. A notation of “Old records reviewed” or
“Additional history obtained from family” without elaboration
is not suf ficient.
 Discussion about results of laboratory, radiology, or other
diagnostic tests with the physician who performed or
interpreted the study should be documented.
 The direct visualization and independent interpretation of an
image, tracing, or specimen previously or subsequently
interpreted by another physician should be documented.
RISK OF SIGNIFICANT COMPLICATIONS,
MORBIDIT Y, AND/OR MORTALIT Y
The risk of significant complications, morbidity, and/or
mortality is based on the risks associated with the
following categories:
• Presenting problem(s);
• Diagnostic procedure(s); and
• Possible management options.
The assessment of risk of the presenting problem(s) is
based on the risk related to the disease process
anticipated between the present encounter and the next
encounter.
MEDICAL DECISION MAKING
The assessment of risk of
selecting diagnostic procedures
and management options is
based on the risk during and
immediately following any
procedures or treatment. The
highest level of risk in any one
category determines the overall
risk.
The level of risk of significant
complications, morbidity, and/or
mortality can be:
•Minimal;
•Low;
•Moderate; or
•High
SOME IMPORTANT POINTS THAT SHOULD BE
KEPT IN MIND WHEN DOCUMENTING LEVEL
OF RISK ARE:
 Comorbidities/underlying diseases or other factors that
increase the complexity of medical decision making by
increasing the risk of complications, morbidity, and/or
mortality should be documented;
 If a surgical or invasive diagnostic procedure is ordered,
planned, performed or scheduled at the time of the E/M
encounter, the type of procedure should be documented;
 The referral for or decision to perform a surgical or invasive
diagnostic procedure on an urgent basis should be
documented or implied
Risk of Significant Complications, Morbidity, and/or Mor tality,
cont.
The table on the next couple of pages may be used to assist in
determining whether the level of risk of significant complications,
morbidity, and/or mortality is minimal, low, moderate, or high.
Because determination of risk is complex and not readily
quantifiable, the table includes common clinical examples rather
than absolute measures of risk.
NEW VS ESTABLISHED PTS
 No face-to-face professional services received from the
physician or another physician of the same specialty and sub specialty who belongs to same group practice for three years
 Internal Medicine and Family Practice are considered
dif ferent specialty
 Patient seen by physician covering or on-call physician
considered patient of usual doctor and is not a new patient
PUTTING IT TOGETHER
History
Exam
Medical
Decision
Making
E&M
REFERENCES
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for
Medicare & Medicaid Services (Evaluation and Management
Services Guide)
“The Art of E&M Auditing” by Intelicode
Per Internet Only Manual (IOM) Medicare Claims Processing
Manual, Publication 100-04, Chapter 12, section 30.6.1