E&M Coding- It’s All
About The
Documentation
Presented for Anthem Blue Cross and Blue Shield
By: Penny Osmon, BA, CPC
Coding & Reimbursement Educator WI Medical Society
Wisconsin Medical Society, Copyright 2007
CPT codes, descriptions and material only are Copyright 2006 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values or related listings are included in applicable FARS/DFARS restrictions to government use.
Review of Coding
Basics
For every patient encounter:
• Assess the patient’s chief complaint/condition (the reason for the visit).
• Document the service rendered and medical necessity in the medical record.
• Bill the appropriate CPT/ICD-9 code that reflects the service rendered and documented.
• Medical necessity of the visit determines the level of service, not the volume of documentation.
E/M Coding
• Above all else, medical necessity has to be
there!
The Progress Note
• S ubjective
• O bjective
• A ssessment
• P lan
Chief Complaint
• Chief Compliant (CC)
– “The CC is a concise statement
describing the symptom, problem,
condition, diagnosis, physician
recommended return, or other factor that
is the reason for the encounter, usually
stated in the patient’s words.”(DGs 1995
& 1997)
Chief Complaint
• The CC is NOT synonymous for the HPI.
• The CC must be in every note.
• Only problem focused visits should have a
HPI.
• Preventive services (ie: annual exam) should
not have an HPI
• Only billing provider can perform the HPI.
History
• Both 95’ and 97’ Documentation guidelines state that the History component is comprised of the following four categories:
• Chief Complaint (CC)
• History of Present Illness (HPI) or
– the status of 3 chronic conditions
• Review of Systems (ROS)
• Past, Family, Social History (PFSH)
Good Examples of the
Chief Complaint
• The patient presents today with a 3d history of hip
pain.
• CC: hip pain.
• Patient here for evaluation of hip pain.
• The patient is here for follow-up of her hip pain.
• Pt presents for her annual exam and CC: of hip
pain.
The History of
Present Illness (HPI)
• ‘The HPI is a chronological description
of the development of the patient’s
present illness from the first sign
and/or symptom or from the previous
encounter to the present.’ (DGs 1995
& 1997)
HPI
• HPI Elements (8)
– Location; Where?
– Quality; Constant, Sharp?
– Severity; Scale of 1-10 – Duration; How long?
– Timing; Nocturnal, Diurnal?
– Context; When does it occur?
– Modifying factor; What makes it better or worse?
– Associated signs/symptoms; Additional Information
HPI
• Example of a Brief HPI
– CC: Abdominal pain
– S: Patient has complaints of right sided abdominal (location) pain for one day (duration).
• Example of a Detailed HPI
– CC: Abdominal pain
– S: Patient has complaints of constant (quality) right sided abdominal (location) pain for one day (duration) associated with vomiting (associated signs &
symptoms)
Review of Systems
• Constitutional
• Eyes
• Ears, Nose, Throat, Mouth
• Respiratory
• Cardiovascular
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Integumentary (skin/breast)
• Neurological
• Psychiatric
• Endocrine
• Hematologic/Lymphatic
• Allergy/Immunologic
Review of Systems
(ROS)
• An inventory of body systems obtained
through a series of questions seeking to
identify signs and/or symptoms which the
patient may be experiencing or has
experienced. (CPT, 2007)
• DG: The patient’s positive responses and
pertinent negatives for the system related to
the problem should be documented.
Review of Systems
• It is permissible in a complete ROS for the
remaining systems where there are no pertinent responses to make a notation indicating “all other systems reviewed and are negative”. This phrase indicates that 10 systems were reviewed and
any positive or pertinent negative findings are individually documented in the note. (WPS
Medicare Communiqué, November 2003)
ROS ~ Good
Examples
1. The patient denies having a fever, chills, ear pain or a sore throat. She has had a productive cough for some time now, but denies SOB. Denies chest pain.
Her appetite has been okay. (Detailed ROS)
2. The patient denies having a fever, chills, ear pain or a sore throat. She has had a productive cough for some time now, but denies SOB. Denies chest pain. Her appetite has been okay. She is voiding in normal amounts. All other systems were reviewed and negative. (Comprehensive ROS)
ROS ~ Bad
Examples
1. The complete ROS was performed in detail and was negative.
2. A 12-point ROS was performed in detail with the patient and is negative.
3. Patient has a runny nose and sore throat and the remainder of the ROS is negative.
4. The patient wears glasses and is diabetic and all other systems are negative.
5. ROS per history form in chart.
6. ROS per the HPI, otherwise negative.
• Past medical history (PMH) - the patient’s past experience with illness, injuries and treatments
• Family history (FH) - a review of medical events in the patient’s family, including diseases which may be
hereditary or place the patient at risk
• Social history (SH) - an age-appropriate review of past and current activities
Past, Medical,
Family and Social
History
Past, Medical, Family
and Social History
(PFSH)
• DG: A ROS and/or 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. The review and
update may be documented by:
– Describing any new ROS and/or 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.
Important Tidbits
• If unable to obtain history from the patient,
eg. intubated, mentally challenged, then
describe the patient’s condition or other
circumstances which precludes obtaining
the history.
• PFSH and ROS can be obtained by ancillary
staff.
Caution!!
• Non-contributory:
– The term “non-contributory” is ambiguous…
some providers take it to mean the system was not relevant, therefore was not reviewed…
while other providers take it to mean that the system was reviewed, but had no pertinent
findings to be reported. Avoid using the term
“non-contributory”.
95’ or 97’ Guidelines
• Examination: The extent of the examination
performed is dependent on clinical judgment and on the nature of the presenting problem(s).
• Can use either the 1995 or 1997 DGs.
• 1995 recognizes body areas and organ systems, but does not specify the extent of exam.
• 1997 recognizes specific bulleted elements.
The Exam
• Examination
– HEENT is not an organ system, but an acronym – Avoid stating HEENT negative
– Hepatosplenomegaly vs organomegaly – Unremarkable or noncontributory
– Use approved abbreviations
– Musculoskeletal exam: no edema (edema is considered exam of cardiovascular system)
– Alert and oriented = Constitutional exam
– Alert and oriented x 3 = Psychological exam
The Exam
• DG: For each encounter, an assessment,
clinical impression, or diagnosis should be
documented.
• For chronic conditions the status of the
condition should be described, eg stable,
well controlled; simply stating HTN without
further elaboration would not be sufficient
documentation.
Medical Decision
Making (MDM)
• Need to document ‘what’ test and ‘why’.
• The guidelines state that the rationale may be ‘easily inferred’, but would suggest clearly documenting
the reason for any testing.
• Evidence-based criterion supports medical necessity and medical necessity support billing services.
• Avoid practices ‘just because we always have.’
Examples of Good
MDM
• Direct visualization/interpretation of image,
tracing or specimen should be documented.
• Example:
– I personally obtained and interpreted the wet prep for clue cells.
– X-ray report shows no fracture, however, my review of the films reveals a hairline fracture…
Billing Based on
Time
• DG: If the physician elects to report the level of
service based on counseling and/or coordination of care, the total length of time of the encounter
(face-to-face or floor time, as appropriate) should be documented and the record should describe the counseling and/or activities to coordinate care.
• The extent of the counseling and/or coordination of care must be documented in the medical record.
(CPT, 2007)
Good Examples of
Documenting Time
– I spent 40 minutes with the patient and greater than 50% of the time was spent discussing her new diagnosis of depression and counseling her about the management options.
– Total floor/unit time was 20 minutes and greater than 50% of that time was spent with patient and family discussing patient’s prognosis and treatment plan.
– 30 minutes spent with patient in discussion regarding her new diagnosis of diabetes and the entire time was spent in
counseling.
Bad Examples of
Documenting Time
– Today’s visit took over 20 minutes.
– I spent 15 minutes counseling the patient.
– Total floor/unit time was 35 minutes.
– Spent 20 minutes above and beyond the usual time for performing the physical exam.
Penny Osmon, BA, CPC
Coding & Reimbursement Educator The Wisconsin Medical Society
[email protected] 608-442-3781
Thank You
The information presented and responses to the questions posed are not intended to serve as coding or legal advice. Many
variables affect coding decisions and any response to the limited information provided in a question is intended only to provide general information that might be considered in resolving coding issues. All coding must be considered on a case-by-case basis and must be supported by appropriate documentation in the medical record. Therefore, the Wisconsin Medical Society recommends consulting directly with payers to determine specific payers’
guidance regarding appropriate coding and claim submission.
The CPT codes that are utilized in coding claims are produced and copyrighted by the American Medical Association (AMA).
Specific questions regarding the use of CPT codes may be directed to the AMA.
