Name of Manual - Blue Cross and Blue Shield of Minnesota

Evaluation and
Management (E/M)
(continued)
Coding Policies and Guidelines (Medical Services)
Each page in the medical record must contain the patient’s
name and/or identification number.
All encounters/entries must be dated.
Services not clearly documented are not covered by Blue Cross
and will be denied as participating provider liability. Failing to
submit requested medical records may result in claims being
denied or payment being recouped from a provider. Patients
are not financially liable for services that are denied for
inadequate documentation.
What information would constitute as a plan of care?
For a physician’s note to qualify as a plan of care, it would need to
contain at least:
the patient’s diagnosis,
long term goals,
and the type, amount, duration and frequency of services.
It must be established before treatment has begun and may be
adjusted by the appropriate practitioner.
Time Documentation
The time spent face-to-face with either the patient or family should
be noted for every service. This is particularly important in a
situation where counseling and/or coordination of care dominates
more than 50 percent of the face-to-face physician time. In this
situation, time is considered the key or controlling factor, and the
extent of counseling and/or coordination of care must be
documented in the medical record.
Consider that in an eight or nine hour work day; there are a given
number of time units which may be allocated to E/M services.
Obviously, the collective time reported, as reflected in the choice
of E/M services codes, cannot exceed the amount of time available
in the work day.
Blue Cross and Blue Shield of Minnesota Provider Policy and Procedure Manual (06/20/12)
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