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Everything You Need to Know About E/M Documentation

Everything You Need to Know About E/M Documentation

Importance of E/M Documentation

A significant portion of your practice’s billable services are comprised of evaluation and management (E&M) services.  According to CMS documentation guidelines, it’s critical for all entries in a medical record to be legible. Any nursing notes, orders, progress notes, and other entries in medical records that aren’t legible can result in misinterpretation or misreading, which could lead to medical errors. It’s possible for claims to be denied simply because E&M documentation was illegible and was not able to be correctly coded. E&M codes documentation, or lack thereof, is one of the big reasons for claim denials. Many clinicians fail to make the connection between poor, incomplete, or inaccurate documentation and falling practice revenue. In this article, we discussed everything you need to know about E/M documentation.

Everything about E/M Documentation

The levels of Evaluation and Management (E/M) services are based on four types of history: problem focused, expanded problem focused, detailed and comprehensive. Each type of history includes some or all of the elements like Chief Complaint (CC); History of Present Illness (HPI); Review of systems (ROS); and Past, family and/or social history (PFSH)

  • Contributory Factors: Contributory factors include counseling; coordination of care; nature of presenting problem; time. Coordination of care with other providers can be used in case management codes. Time can be used for some codes for face-to-face time, non-face-to-face time, and unit/floor time. Time is used when counseling and/or coordination of care is more than 50 percent of your encounter. The extent of history of present illness, review of systems, and past, family and/or social history that is obtained and documented is dependent upon clinical judgment and the nature of the presenting problem(s).
  • Chief Complaint (CC): A concise statement describing the reason for the encounter. The CC should be clearly reflected in the medical record for each encounter and is usually stated in the patient’s words. The CC can be included in the description of the history of the present illness or as a separate statement in the medical record.
  • History of Present Illness (HPI): A description of the development of the patient’s present illness. The HPI is usually a chronological description of the progression of the patient’s present illness from the first sign and symptom to the present. It should include some or all of the elements like location, quality, severity, duration, duration, timing, context, modifying factor, associated signs & symptoms.

Medical Decision Making (MDM)

Number of diagnoses or management options; amount and/or complexity of data to be reviewed; risk of complications and/or morbidity and mortality; and type of decision making are elements required for each level of medical decision making. To qualify for a given type of decision making, two of the three elements must be either met or exceeded.

Number of Diagnoses 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. Generally, decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem. The number and type of diagnostic tests employed may be an indicator of the number of possible diagnoses.

Problems which are improving or resolving are less complex than those that are worsening or failing to change as expected. The need to seek advice from others is another indicator of complexity of diagnostic or management problems.

  • For each encounter, an assessment, clinical impression or diagnosis should be documented. It 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: 1) improved, well controlled, resolving or resolved; or 2) 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 a differential diagnoses or as “possible,” “probable,” or “rule out” (R/O) diagnoses.
  • 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 the advice is requested.

Amount and/or Complexity of Data to be Reviewed: The amount and complexity of data to be reviewed is based on the types of diagnostic testing ordered or reviewed. 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 is an indication of the complexity of data being reviewed. On occasion, the physician who ordered a test may personally review the image, tracing or specimen to supplement information from the physician who prepared the test report or interpretation. This is another indication of the complexity of data being reviewed.

If a diagnostic service (test or procedure) is ordered, planned, scheduled, or performed at the time of the Evaluation and Management (E/M) encounter, the type of service (i.e. lab or x-ray) should be documented. The review of lab, radiology and/or other diagnostic tests should be documented. An entry in a progress note such as “WBC elevated” or “chest x-ray unremarkable” is acceptable. Alternatively, the review may be documented by initialing and dating the report containing the test results. A decision to obtain old records or decision to obtain additional history from the family, caretaker or other source to supplement that obtained from the patient should be documented.

Relevant findings from the review of old records, and/or the receipt of additional history from the family, caretaker or other source should be documented. If there is no relevant information beyond that already obtained, that fact should be documented. A notation of “old records reviewed” or “additional history obtained from family” without elaboration is insufficient. The results of discussion 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, Morbidity and/or Mortality: The risk of significant complications, morbidity and/or mortality is based on the risks associated with the presenting problem(s), the diagnostic procedure(s), and the possible management options. 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, or scheduled at the time of the E/M encounter, the type of procedure (i.e. laparoscopy) should be documented. If a surgical or invasive diagnostic procedure is performed at the time of the E/M encounter, the specific 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.

Past Family Social History (PFSH)

The Past, Family and/or Social History (PFSH) includes a review in three areas:

  • Past History: The patient’s past illnesses, operations, injuries, medications, allergies and/or treatments
  • Family History: The review of the patient’s family and their medical events, including diseases which may be hereditary or place the patient at risk
  • Social History: An age appropriate review of past and current activities (i.e. job, marriage, exercise, marital status, etc.)

A pertinent PFSH is a review of the history area(s) directly related to the problem(s) identified in the History of Present Illness (HPI). At least one specific item from any of the three history areas must be documented for a pertinent PFSH. A complete PFSH is of a review of two or all three of the PFSH history areas, depending on the category of the Evaluation and Management (E/M) service. A review of all three history areas is required for services that by their nature include a comprehensive assessment or reassessment of the patient. A review of two of the three history areas is sufficient for other services.

At least one specific item from two of the three history areas must be documented for a complete PFSH for the following categories of E/M services: office or other outpatient services, established patient; emergency department; subsequent nursing facility care; domiciliary care, established patient; and home care, established patient. The PFSH may be listed as separate elements of history, or they may be included in the description of the history of the present illness.

A PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information This may occur when a physician updates his/her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:

  • Describing any new PFSH information or noting there has been no change in the information; and
  • Noting the date and location of the earlier ROS and/or PFSH

The PFSH may be recorded by ancillary staff or on a form completed by the patient.To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others. If the physician is unable to obtain a history from the patient or other source, the record should describe the patient’s condition.

Review of Systems (ROS)

The Review of Systems (ROS) is an inventory of the body systems that is obtained through a series of questions in order to identify signs and/or symptoms which the patient may be experiencing. The Centers for Medicare and Medicaid Services (CMS) recognizes 14 systems as: Constitutional symptoms (i.e. fever, weight loss, vital signs); Eyes; Ears, nose, mouth, throat; Cardiovascular; Respiratory; Gastrointestinal; Genitourinary; Musculoskeletal; Integumentary; Neurological; Psychiatric; Endocrine; Hematologic/Lymphatic; and Allergic/Immunologic.

There are a couple of document guidelines for the ROS that you should be aware of when it comes to your patient’s medical record. A ROS obtained during an earlier encounter does not have to be documented again if there is evidence that the physician reviewed and updated the previous information. The review and update may be documented by describing any new ROS or noting there has been no change in the information. The physician will also have to document the date and location of the earlier ROS in the present encounter. Another guideline is that a staff member may document the ROS in the medical record as long as there is evidence that the provider reviewed their documentation.

You have to reference the date of the last ROS if referring to this in your present note. You cannot state review of systems unchanged from last visit, the date is needed. Considering “History”, you will note that there are three levels to choose from:

  • A “problem pertinent” ROS inquires about the system directly related to the problems(s) identified in the HPI. Documentation needs to include the positive responses and pertinent negatives for the system related problem.
  • An “extended” ROS inquires about the system directly related to the problems(s) identified in the HPI and a limited number of additional systems. Documentation needs to include the positive responses and pertinent negatives for two to nine systems.
  • A “complete” ROS inquires about the system directly related to the problems(s) identified in the HPI plus all additional body systems. At least ten systems need to be reviewed. Those systems with positive responses and pertinent negatives must be individually documented. For the remaining systems, a notation indicating all other systems are negative is allowed.

Legion Health Care Solutions is a leading medical billing company providing complete billing and coding services to ensure accurate insurance reimbursement for your practice. We referred CMS documentation guidelines and practice support documents from ‘American College of Cardiology’ to discuss everything about E/M documentation. In case of any assistance needed in medical billing for your practice, contact us at 727-475-1834 or email us at info@legionhealthcaresolutions.com

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