TrailBlazer Health Enterprises

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EDUCATION MAKES THE DIFFERENCE
Documenting Components of an Established Office E/M Service
Evaluation and Management (E/M) services are the group of codes responsible for most of
the Paid Claims Error Rate. Among these E/M services identified as error prone are the most
basic of the E/M encounters, established office visits. This job aid addresses the E/M coding
and documentation errors frequently identified by TrailBlazer SM medical review auditors. It
uses an established office visit sample to illustrate some of the most common E/M coding
errors but, because of similarities between established office visits and other E/M services,
most or all of the comments here should be applied to coding other E/M families of codes.
The sample record below illustrates deficiencies commonly found within medical records for
established office visit services received by TrailBlazer. Try your hand at determining the
appropriately reimbursed E/M code considering medical necessity and key component work.
Then check Medicare’s comments about the case to compare with your own impressions.
Patient Name: John Doe Date of Service: 05/05/2010
Date of Birth: 01/01/1935
Chief Complaint (CC): Osteoarthritis
History of Present Illness (HPI):
75-year-old male with a history of osteoarthritis.
Review of Systems (ROS):
Constitutional symptoms – No fever, no loss of appetite.
Cardiovascular – Negative for chest pain.
Respiratory – No shortness of breath.
Gastrointestinal – No nausea or vomiting.
Genitourinary – No difficulty urinating.
Musculoskeletal – Pain in joints intermittently.
Integumentary – No rash.
Neurological – Denies disorientation.
Endocrine – No cold intolerance.
Allergic/Immunologic – Positive for seasonal hay fever.
Past, Family, Social History (PFSH):
See visit record for date of service 01/01/2010.
Published November 2010

Physical exam:
Vital signs – T 98.7, P 76, R 20, BP 130/80.
Head, Ears, Eyes, Nose, Throat – Oropharynx clear, no mucosal ulcerations and auditory
canals clear. PERRLA.
Neck – Trachea midline, supple.
Lungs – Clear to auscultation bilaterally.
Cardiovascular – Regular rhythm and rate.
Abdomen – Soft, non-tender.
Extremities – Normal.
Musculoskeletal – Bilateral knees with normal range of motion, crepitus on motion, pain
with ambulation rated 3 out of 10 and tenderness upon palpation.
Neurologic – Oriented to time, place and person.
Hematologic/Lymphatic/Immunologic – No bruising, no lymphatic swelling.
Skin – Normal temperature, turgor and texture. No rash.
Psychiatric – Appropriate mood and affect.
Assessment:
Occasional joint pain.
Plan:
1. Continue same treatment.
2. Return to office in three months.
Medically Reasonable and Necessary
The law requires all payments (with only a few exceptions) made by Medicare to be for
medically reasonable and necessary services. Medicare determines “medically reasonable
and necessary” separately from determining that the work described by a reported CPT code
was performed. For E/M services, the medical record documentation must demonstrate that
the practitioner performed the reported E/M service as it is described in the CPT book and as
required by CMS E/M Documentation Guidelines. Additionally, it must support the intensity
and frequency of the E/M service met but that it did not exceed the patient’s clinical needs.
Information within the medical record about the patient’s condition, not the diagnosis alone,
determines the level of service payable by Medicare. In keeping with federal law, Medicare
must deny or downcode E/M services that, in its judgment, exceed the patient’s documented
needs.
Documenting Medical Necessity
The patient’s condition (severity, acuity, number of medical problems, etc.) is the key factor in
determining medical necessity for Medicare payment for services. Providers who report E/M
services for Medicare payment must ensure their records describe the patient’s condition and
reason for the visit in enough detail for a reasonable observer to understand the patient’s
need. Providers must also ensure the nature of the patient’s presenting problem and/or status
is consistent with the level of service reported. Unfortunately, practitioners often include
unnecessary material while failing to record clinically pertinent information needed to
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determine medical necessity of the service. The service should be coded based on the
clinical needs of the patient.
Level of Service
The E/M code chosen must reflect both work performed and medical necessity. Though an
E/M service may code to a high level based on the documentation of key component work, it
is inappropriate to request Medicare payment when the patient’s effective management does
not require the code’s work.
Comments on the Sample
The patient presented with a single, chronic, well-controlled problem. Unfortunately, the
practitioner’s explanation of the nature of this patient’s problem is too vague to even get a
sense of whether this service is at all medically necessary. Osteoarthritis is a chronic problem
that appears to be stable in this patient. Is a three-month follow-up reasonable and necessary
for stable osteoarthritis? Why or why not? Those are the questions the information in the
record should address for Medicare payment to be determined appropriate.
If one assumes this was a medically reasonable and necessary visit, what level of service is
needed for a follow-up visit with a patient who has one stable problem (for which the
likelihood of death or disability before the next visit is very unlikely)? The answer is that this
visit would appropriately be paid as a low-level E/M service, probably code 99212.
Consequently, while the very brief HPI and Medical Decision-Making (MDM) could be
appropriate for the care of this patient’s osteoarthritis, the comprehensive ROS and
examination exceeded the level of care needed for the patient’s presenting condition.
Physician Work
The following sections will primarily deal with the other contributor to E/M coding, physician
work. There are three key components used to distinguish the parts of an E/M encounter: the
history, physical examination and medical decision-making. TrailBlazer and other auditors
find commonly committed errors with each of the key components.
History Component
The history is further categorized into four subcomponents: Chief Complaint (CC), History of
Present Illness (HPI), Past Family and Social History (PFSH) and Review of Systems (ROS).
Because CMS E/M guidelines dictate that the independently assigned level of each of these
four components is considered when coding the history key component, insufficient
documentation of any subcomponent can and often does result in incorrect coding of
the entire service. In addition, information contained in the history is absolutely
necessary to substantiate medical decision-making and medical necessity, not just of
the E/M service but of any and all resulting diagnostic and/or therapeutic services
reported.
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The elements required for each type of history are depicted in the table below.
Type of
History
CC HPI ROS PFSH
Problem- Required Brief N/A N/A
Focused
Expanded Required Brief Problem N/A
Problem-
Focused
Pertinent
Detailed Required Extended Extended Pertinent
Comprehensive Required Extended Complete Complete
Chief Complaint and History of Present Illness
The reason for the visit for every E/M service that is payable by Medicare must be clearly
stated or easily inferred in the CC and HPI. Often the reason for the visit is included in a brief
statement written in the patient’s own words by an ancillary staff member. A statement of
“follow-up” and/or simply listing the diagnosis for which the patient seeks care is insufficient
for anyone, either another clinician or a payer’s auditor, to understand why this patient needs
medical care at this particular time. The CC and HPI contextualize the remaining record of
the encounter. All other work components for the encounter must relate to the patient’s CC or
any new problem identified that requires care for the service to be medically reasonable and
necessary.
It should be easy to spot the missing HPI in this record. The HPI must describe the patient’s
symptoms, the evolution of his illness and the present status of his condition. The HPI
includes the following elements about the presenting complaint, as applicable: location,
quality, severity, duration, timing, context, modifying factors, and associated signs
and symptoms. The reason for an established office encounter is absent in our sample. This
sample does not describe the patient’s symptoms, the evolution of his illness or the status of
his condition in any manner. The absence of the HPI renders this record useless for
understanding the patient’s condition or the necessity for Medicare payment for the service.
Every level of an E/M service requires an HPI. According to the CMS E/M documentation
guidelines, the HPI is classified as either brief or extended, depending on the recorded
characterization of the clinical problem. A brief HPI requires one to three elements whereas
an extended HPI requires four or more elements. CPT codes 99214 and 99215 require an
extended HPI.
The 1997 Documentation Guidelines for Evaluation and Management Services offer another
option for scoring the HPI by stating the status of relevant chronic problems. (The 1995
Documentation Guidelines for Evaluation and Management Services do not apply to this
approach.) The status is a description of the condition’s state now compared to a previous
encounter. Using this method, the level of HPI is classified as either:
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Brief (by inference from the E/M guidelines) – Status of fewer than three chronic
problems).
Or,
Extended – Status of three or more chronic problems.
It is important to remember, when documenting the status of three chronic problems in lieu of
the elements required for an extended HPI; the visit must necessitate evaluation of the
chronic conditions. Additionally, it is insufficient to code for the status of a condition simply
documented with the name of the condition or with a conclusory statement such as “stable,”
“worsening,” etc.
The bottom line is that without an HPI, the history key component cannot be considered as
one of the two key components necessary for coding established office visit services. In
addition, with inadequate history, medical necessity for the visit is absent. Finally, without
history, it is usually impossible to establish medical necessity for related diagnostic testing
and therapeutic intervention. In short, avoiding recording a clinically meaningful HPI severely
limits the usefulness of the record for payer purposes, but also for other record purposes
such as liability defense and quality of care questions.
Review of Systems
The ROS is a required element for all of the types of history except the problem-focused
history. The ROS consists of an inventory of body systems obtained through a series of
questions seeking to identify signs and/or symptoms that the patient may be experiencing or
has experienced. It should include the patient’s subjective responses to the practitioner’s
probing questions. The ROS is important because it sets the stage for which systems need a
more in-depth examination by the practitioner.
The ROS must include information regarding the involved system and any related system(s).
The work of obtaining the ROS should be considered as additional work to that of the HPI,
though there can be overlap between the information recorded as the HPI element called
“associated signs and symptoms.” It is not appropriate to state “see HPI” for the ROS and
then consider the same information recorded in one of the two places for both HPI and ROS.
When documenting the patient’s response to questions, never document any system’s review
as “positive” without elaboration, and never document the system related to the
presenting problem as “negative.” Statements such as “normal” or “negative” may be used
to document asymptomatic systems not related to the presenting problem only. Additionally,
the provider must identify which systems were “negative” when using this term.
Be careful not to record physical observations as the ROS. For example, documenting
“abdomen soft, non-tender” is inappropriate for the gastrointestinal ROS. Appropriate
documentation might be recorded as “denies abdominal pain, nausea or vomiting.”
Remember, the patient is answering the provider’s questions. Would a practitioner ask a
patient if their abdomen is soft and non-tender? He probably would not.
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Do not document past history as ROS. For example, “history of thyroid disease” is not a
systemic review. The review of the endocrine system includes questions about signs and
symptoms (such as cold intolerance, heat intolerance, tremor, hair loss, weight loss or gain,
etc.), not past medical or surgical diagnoses/procedures. The sample lists 10 systems, but
close inspection reveals that the final one, allergic/immunologic, is not a systemic review but
is a past history item.
Finally, whether considering this ROS as extended (two to nine systems) or complete (10 or
more systems), its content is probably not consistent with the nature of the patient’s
presenting problem recorded. The ROS must be appropriate for the clinical
circumstances of the encounter. In the sample documentation, the ROS exceeds the level
needed for the patient’s presenting condition. Do not record unnecessary information
solely to meet requirements of a higher-level service when the nature of the visit dictates
a lower-level service to be medically appropriate.
Past, Family and/or Social History
The PFSH consists of a review of three areas:
Past history – Past experiences with illnesses, operations, injuries and treatments.
Family history – Medical events in the patient’s family, including diseases that may be
hereditary or place the patient at risk.
Social history – An age-appropriate review of past and current activities.
The amount of documentation required for the PFSH depends on the nature of the patient’s
presenting problem. If the problem is self-limiting and/or the encounter is for a chronic, stable
problem, then a complete PFSH usually does not add value to the patient’s care. A more
complex problem(s) may require a more in-depth PFSH. Remember to consider the CC, the
ROS or any newly identified problems when obtaining the PFSH. PFSH can also include
review of the patient’s current medications. For most follow-up visits for chronic problems,
this may be the most crucial and the only clinically relevant PFSH information.
For established office visit services, there are two categories for the PFSH: pertinent and
complete. A pertinent PFSH is a review of the history area directly related to the problem(s)
identified in the HPI, while a complete PFSH is a review of two or all three of the PFSH
history areas.
In the documentation sample, the PFSH documentation referenced another medical record
on another date of service. This approach to documenting the PFSH is only sufficient if there
is evidence that the physician reviewed and updated the previous information. To document
the review and update the previous information, the provider should:
Describe any new PFSH information or note there has been no change in the
information.
Note the date and location of the earlier PFSH.
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Note: When using this method, providers must submit records for the prior date notated in
the event of a medical record audit.
Examination
We know already that the medical necessity coding for this service is a low-level service in
the 99212–99213 range. We also know that the history given here is not codeable at all
because of its absent HPI. Starting from the point of view that the highest code allowable for
this service is 99213 makes it reasonable to focus our discussion of this service on the
required examination for codes 99212 and 99213.
Documenting the Examination
Providers should document the examination according to body area(s) and/or organ
system(s). Medicare recognizes the body areas and organ systems listed on the chart below
for the purposes of examination. The E/M documentation guidelines are very specific about
when body areas may be considered and when organ systems may be considered. There are
minute but important differences between 1995 and 1997 guidelines with respect to this
wording. It is important to understand this distinction and apply it when documenting
examinations. Technically, CMS has stated that providers are to use one guideline or the
other in its entirety and should not “pick and choose” to apply different sections from the two
sets. TrailBlazer understands the complexity of these particular nuances of E/M
documentation guidelines and reviews medical records considering the entirety of the record,
the work documented and medical necessity of the service. However, this is one area where
lack of care and consistency can lead to payment errors, especially when the service is
coded using the most favorable “sections” of the different guidelines causing the overall
work/medical necessity for the encounter to be overestimated.
The chart below provides the body areas and organ systems recognized in the E/M
Documentation Guidelines.
Body Areas
Head, including the face.
Neck.
Chest, including breasts and axillae.
Abdomen.
Genitalia, groin, buttocks.
Back, including spine.
Each extremity.
Organ Systems
Constitutional (e.g., vital signs, general
appearance).
Eyes.
Ears, nose, mouth and throat.
Cardiovascular.
Respiratory.
Gastrointestinal.
Genitourinary.
Musculoskeletal.
Skin.
Neurologic.
Psychiatric.
Hematologic/lymphatic/ immunologic.
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Below are additional guidelines for documenting the examination appropriately.
The documented examination must be appropriate for the clinical circumstances of the
encounter or Medicare will deny the E/M service or downcode it to the appropriate level if the
level billed exceeds the patient’s need. The following are important tips to keep in mind when
documenting the examination findings:
Describe specific abnormal and relevant negative findings of the affected or
symptomatic body area(s) or organ system(s):
o Always examine the system(s) related to the presenting problem and do not
describe it as “normal” or “negative.”
o Elaborate on any notations of “abnormal.”
Describe abnormal or unexpected findings of the unaffected or asymptomatic body
area(s) or organ system(s).
A brief statement or notation indicating “negative”, “normal” or “WNL” is sufficient to
document normal findings related to unaffected area(s) or asymptomatic organ
system(s). However, documenting in this fashion assures limitation of coding to
“limited examination” as described in the table below.
Level of Examination
The practitioner should select the type (general multisystem or single organ system) and
content of an examination utilizing clinical judgment, the patient’s history and the nature of
the presenting problem(s). Medicare recognizes four types of examinations according to CPT
guidelines. The chart below shows the types of examinations and the individual requirements
for each type.
Type of
Examination
Problemfocused
Expanded
problemfocused
1995
Definition of
Examination
Limited
exam of the
affected
body area or
organ
system
Limited
exam of the
affected
body area or
organ
system and
other
symptomatic
or related
1995
Guideline
Requirements
One body area
or organ
system
Two to seven
body areas
and/or organ
systems
1997
Definition of
Examination
Limited
exam of the
affected
body area or
organ
system
Limited
exam of the
affected
body area or
organ
system and
other
symptomatic
or related
1997
Guideline
Requirements
One to five
bulleted
elements
Six to 11
bulleted
elements
CPT
Code
99212
99213
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Type of
Examination
Detailed
1995
Definition of
Examination
organ
system(s)
Extended
exam of the
affected
body area(s)
and other
symptomatic
or related
organ
system(s)
Comprehensive General
multisystem
exam or
complete
exam of a
single organ
system
1995
Guideline
Requirements
Two to seven
body areas
and organ
systems
Eight or more
body areas
and/or organ
systems
1997
Definition of
Examination
body areas
or organ
system(s)
Extended
exam of the
affected
body area(s)
and any
other
symptomatic
or related
body areas
or organ
system(s)
General
multisystem
exam or a
complete
exam of a
single organ
system and
other
symptomatic
or related
body area(s)
or organ
system(s)
1997
Guideline
Requirements
12–17 bulleted
elements for
two or more
systems
18 or more
bulleted
elements for
nine or more
systems or
see
requirements
for individual
complete
single-system
exams
CPT
Code
99214
99215
When determining the level of examination, consider the clinical circumstances of the
encounter. Do not select the type of examination on excessive and unnecessary
information recorded solely to meet the requirements of a higher-level service when
the nature of the visit dictates a lower-level service to be medically appropriate. The
documentation sample above provides an example of the examination exceeding the level
needed for the patient’s presenting condition.
Expanded Problem-Focused Versus Detailed
As with the history component, each successive type of examination requires more
information than the previous one. Each successively higher examination level varies with the
respect to the following:
Number of body areas and/or organ systems examined.
Amount of information recorded about each body area or organ system.
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The exception to the above statement is the 1995 Evaluation and Management
Documentation Guideline requirements for Expanded Problem-Focused (EPF) and Detailed
examinations, which require two to seven systems and/or body areas. This exception gives
providers and coders, as well as medical record auditors, difficulty. The 1995 Evaluation and
Management Documentation Guideline for an EPF examination requires a limited
examination of the affected body area or organ system and other symptomatic or related
organ system(s). The detailed examination requires an extended examination of the affected
body area(s) and other symptomatic or related organ system(s). The scope of the detailed
examination is the same as it is for the EPF examination; however, the degree of
thoroughness of the detailed examination is greater.
CMS did not specify the difference, in terms of numbers of items of information about a body
area, that constitutes an extended versus limited examination. Instead, in 1997, CMS
published an entirely different guideline with the differences very apparent in terms of specific
requirements for numbers of “bulleted items.” For medical review purposes, TrailBlazer looks
toward the numbers of items of information listed in the 1997 guidelines and expects a
similar, though not necessarily exact, amount of information when assigning the detailed
examination using the 1995 guidelines.
Below is the exam portion excerpted from the medical record sample. The table below
compares use of the 1995 and 1997 E/M Guidelines with respect to the examination of the
patient and coding of the service.
Application of the 1995 and 1997 E/M Guidelines
Physical Exam 1995 E/M Guideline
1997 E/M Related or Considered
Guideline Symptomatic? for Coding?
Vital signs System System No No
Head Body area Bones, No
No
muscles, joints
considered in
musculoskeletal
system.
Eyes System System No No
Ears, Nose, System System No No
Mouth, Throat
Neck Body area Body Area No No
Lungs System System No No
Cardiovascular System System No No
Abdomen Body area Included in
gastrointestinal
No
No
system.
Extremities Body area Mentioned as
musculoskeletal
Yes
Yes. See
discussion
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Physical Exam 1995 E/M Guideline
1997 E/M Related or Considered
Guideline Symptomatic? for Coding?
system and
below.
skin system.
Musculoskeletal System System Yes Yes. See
discussion
below.
Neurologic System System. Note,
however, that
the finding
“neurologic”
here is
orientation,
which under
1997 is
specified to be
psychiatric
No
No
Hematologic/
Lymphatic/
Immunologic
System. Note that
hematologic/lymphatic
is a separate system
from
allergic/immunologic.
system.
System. Note,
however, the
finding of no
bruising and no
swelling under
1997 guidelines
is skin system.
Hematologic is
not recognized
in 1997.
No
No
Psychiatric System System No No
Discussion on Sample
When examining the case sample and applying the 1995 and 1997 E/M Guidelines, most of
the recorded examination was asymptomatic and not related to the presenting problem or
affected body area. Therefore, it is not counted with respect to coding the work of this case.
An additional, more complicated issue with coding this sample arises with respect to the only
affected body areas/systems, examination of the knees. The documentation about the knees
could represent examination of either two body areas (each lower extremity) or one organ
system (musculoskeletal). The 1995 guidelines give no additional credit for a second body
area for the EPF examination (99212 and 99213), whereas the 1997 guidelines do. However,
both guidelines are silent as to whether two body areas representing a single system can be
counted separately (i.e., counted one as a body area and one as a system).
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Using this case as an example, it appears that one body area (one lower extremity) and one
organ system (the musculoskeletal system for the other lower extremity), might meet
requirements for EPF (99213) under the 1997 guidelines, but depending on individual
interpretation, might represent only Problem-Focused (PF). For consistency purposes,
TrailBlazer has chosen to apply a one-body-part/body-area-per-system rule as well as not
allowing a combination of both guidelines to code a single key component. Therefore, in this
case, under the 1995 guidelines, TrailBlazer would not allow one body area for one knee and
the musculoskeletal system for the other knee. The 1997 guidelines allow two body areas for
the EPF exam and are far more specific with respect to individual examination “bullets.”
Other controversial points occur in this sample (neck versus musculoskeletal and
hematologic/lymphatic/immunologic versus skin). Fortunately, those are irrelevant because
they are not considered for coding this service.
These complex nuances represent some of the difficulty in correcting Medicare payment error
rates for E/M services. CMS created the 1997 guidelines in hopes of eliminating nuances and
subjectivity of the 1995 guidelines. However, many individuals prefer them because of the
lack of specificity. It is important to look at the service work reflected in the record as a whole;
never jump to the higher-level code without a plausible explanation and when medical
necessity for the higher service is not clearly demonstrated.
Overall, the documentation style employed in this sample appears to have been used to
justify upcoding the service. Taking into consideration the above discussion on medical
necessity, the information provided in the medical record sample demonstrates a low-level
service, no matter how much work is documented. Coding based on documentation absent
underlying medical necessity is always inappropriate.
Medical Decision-Making
The MDM component is the third key component of most E/M services. Though the CPT
book ascribes equal weight to the three key components for purposes of coding physician
work, most coders and clinicians should recognize that vital information about the patient’s
condition necessary in determining medical necessity of the encounter is usually located in
the MDM section of the record. The recorded MDM should portray the physician’s thought
evolution about the patient as he synthesizes raw historical and physical information into
diagnostic impressions and treatment plans. Conversely, information about the patient
recorded in the history and physical must support the physician’s impressions and
management plans. Because of this unique dependence on the information contained in the
MDM component, even though a medical record might contain a perfectly complete history
and examination, without a correspondingly complex MDM there may be no justification for
payment of a high-level E/M service. In fact, without adequate record of physician
impressions and planned diagnostic/therapeutic intervention, the encounter might be
rendered of no clinical benefit at all and not payable at any level.
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Documenting MDM adequately is essential for proper claims payment. Many practitioners
and coders falsely equate MDM complexity (from a coding perspective) with severity of the
patient’s condition(s). Presence of a severe or complicated patient condition certainly might
support medical necessity for a complex E/M service, but recall that medical necessity alone,
in the absence of documented physician work, is not a sufficient basis for payment. This is
true of each component of the medical record for an E/M service.
Experience also teaches that many practitioners fail to memorialize in writing much or most of
the decision-making process. Nevertheless, overlooking the documentation of their thoughts
can sabotage an otherwise good clinical record. It can make the difference between an
encounter portrayed on paper as an over-documented simple visit versus a complex clinical
problem that the physician failed to adequately address. You can see the importance of
accurate and complete documentation for the purpose of correct reimbursement of the
service as well as to defend actions in the event of a liability or quality of care charge.
The Basics
Coding MDM work begins by independently coding each of three components of MDM. The
evaluation for each of these three components is then incorporated into the final overall MDM
level score, which is then integrated with the other key components into the final overall CPT
code for the service. The three MDM components are:
The number of possible diagnoses and/or management options.
The amount and/or complexity of data reviewed or ordered.
The risk of complication and/or mortality.
The CPT MDM component descriptions suggest numeric values to correspond with the
potential levels for each component, in contrast to the highly quantified E/M Documentation
Guidelines treatment of the history and physical. CMS did not provide numeric values for
MDM. Therefore, numerous approaches for quantification of the components, especially the
first two, have evolved. There is no official CMS coding instruction to quantify them.
TrailBlazer published its method for quantifying the number of diagnoses/management
options and the amount/complexity of data in a document referred to as the Coding and
Documentation Pocket Reference. CMS has stated that TrailBlazer’s method is consistent
with the content and purpose of the remaining CMS E/M guidelines.
As a final complicating factor, the third component of MDM, risk, has three independent
subcomponents:
Risk of death or disability conferred by the nature of the presenting illness.
Risk conferred by the diagnostic options chosen.
Risk conferred by the therapeutic options chosen.
Before coding the risk component of MDM, one must first code each of the subcomponents.
CMS has provided a table in the E/M guideline to assist with assigning risk for each of the
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subcomponents. The subcomponent with the highest risk determines the overall MDM
component’s risk.
To access detailed information regarding scoring individual MDM components, you may
review the resources:
1995 Documentation Guidelines for Evaluation and Management Services.
1997 Documentation Guidelines for Evaluation and Management Services.
CMS Evaluation and Management Services Guide.
After coding the MDM components, code the overall MDM key component. Medicare
recognizes four types of MDM for established office visit services: straightforward, low
complexity, moderate complexity and high complexity. The chart below shows the
progression of the required components for each level of MDM. To qualify for a given type of
decision-making, two of the three MDM components in the table must be either met or
exceeded. Keep in mind, coding MDM should not be solely based on the severity of or
number of presenting problems; decision-making also encompasses the number of and risk
associated with diagnostic tests ordered/performed as well as the complexity of and risk
associated with therapeutic options chosen.
No. of Possible
Diagnoses and/or
Management
Options
Amount and/or
Complexity of
Data Reviewed or
Ordered
Risk of
Complication
and/or Mortality
Type of
Decision-
Making
Minimal Minimal or none Minimal Straightforward
Limited Limited Low Low complexity
Multiple Moderate Moderate
Moderate
complexity
Extensive Extensive High High complexity
Calculating the Overall MDM Score Using the Components
The table below applies the sample documentation to the three MDM components in order to
calculate the overall MDM score. To show calculation of risk, it is further divided by its three
subcomponents.
MDM Component
Numbers of
problems and
management
options.
Documentation
in the Sample
Chronic knee
osteoarthritis
(inferred from
history) with
occasional joint
pain (stated in
assessment).
Component
Assessment
One problem,
no additional
evaluation
planned.
Component
Score
Minimal
Overall MDM
Score
Straightforward
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MDM Component
Documentation
in the Sample
Component
Assessment
Component
Score
Overall MDM
Score
Amount/complexity
of data.
Risk Components
Presenting
problem
No specific
management
options listed.
No diagnostic
studies ordered
or reviewed.
None
One chronic Low risk
stable illness
Diagnostic None No risk
Therapeutic None No risk
None
Low
Common Documentation Deficiencies
Auditors, coders and others who utilize a medical record often must base decisions, including
claim payment, solely on the record’s content. Therefore, practitioners must ensure that
another person can understand their thought process when documenting MDM. It may be
helpful for the practitioner to have another professional or coder review records from time to
time to ensure the message intended by the authoring provider is transmitted as intended.
Documentation stating “continue same treatment,” while acceptable in the context of
the entire patient record, can be problematic when that record does not reveal what
treatments and for what conditions treatments are being continued. “Continue same
treatment” statements are only sufficient if additional medical records, showing what
the prior treatment was, are submitted along with the medical record requested. A far
better clinical record will be explicit or provide ready access to the needed information.
The MDM must demonstrate that during the encounter the physician addressed the
chief complaint. For example, a practitioner obtains the history and performs an
examination based upon a chief complaint of pain in the knees, followed by the MDM
addressing the patient’s hypertension. Though additional conditions and complaints
that lead to physician work are frequently discovered via the process of obtaining the
history and performing the examination, it is important not to ignore the original reason
for the encounter. Remember to address the chief complaint and document
accordingly.
When documenting MDM, a list of established diagnoses or potential diagnoses is
insufficient for coding purposes without additional indication(s) in the record of
meaningful and necessary evaluation and management for each problem.
Practitioners should record relevant impressions, tentative diagnoses, confirmed
diagnoses and all therapeutic options chosen related to every problem for which
evaluation and management is clearly demonstrated.
Document all diagnostic tests ordered, reviewed and independently visualized.
Ensure the medical record clearly indicates the reason for ordering any diagnostic
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tests. Practitioners should document the association between the diagnostic test and
the diagnoses or potential diagnoses.
Summarize old records or other outside information reviewed and incorporated into
decision-making. The documentation should include the source of this information.
Beware of templates that overestimate decision-making. Practitioners should
understand how their electronic medical records coding calculator was developed.
Understanding the logic of templates and/or computer programs will ensure accurate
selection for the level of MDM provided.
Coding the Overall E/M Service
All three key components are used to determine the final CPT work code. For established
office visits (and most other established/subsequent E/M services), two of the three key
components (history, examination and MDM) must meet or exceed the CPT and
Documentation Guideline requirements. In order to qualify for Medicare payment, the primary
work must be medically reasonable and necessary, and key component work must meet or
exceed requirements of the component used to determine the overall E/M code for the
service provided.
Office services at which more than 50 percent of the physician’s face-to-face time is spent
with the patient and/or family are appropriately coded in consideration of time alone. For such
services documentation must include the amount of time and its relation to the entire visit as
well as a description of the nature of the counseling and/or coordination. Additionally, the
record as a whole must reflect the medical necessity for such counseling/coordination. For
reference, CPT provides the key component requirements and average physician face-toface
time for established office services. Medicare expects times spent in counseling and
coordination, and reported as described above, to be consistent with these CPT-specified
times.
As shown in the table below, the work demonstrated in our case sample is properly coded as
99212. The yellow boxes represent the correct key component coding, with examination
shown as two possible levels depending on one’s interpretation of the guideline. Using
TrailBlazer’s rule, the examination is problem-focused. Either way, the best two of the three
key components yield a final CPT code of 99212 for the service depicted in the sample.
History
Examination
MDM
99212 99213 99214 99215
Problem-
Focused
Expanded
Problem-
Focused
Expanded
Problem-
Focused
Low
Complexity
Problem-
Focused
Straightforward
Detailed
Detailed
Moderate
Complexity
Comprehensive
Comprehensive
High
Complexity
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Average Time
(Minutes)
99212 99213 99214 99215
10 15 25 40
Summary
In our sample, it is evident that from both clinical and coding perspectives, relevant and
important information about the history and physical are missing. From either perspective,
medical necessity or work, the service documented is appropriately paid at a low level
despite its plethora of clinically irrelevant historical and physical information.
Guidance for scoring the level of service is located within TrailBlazer’s “Coding and
Documentation Pocket Reference,” the CPT book’s “E/M Services Guidelines” and CPT E/M
code definitions.
A Better Way?
For low-level services, documentation need not be lengthy. With little or no additional
physician work, the service portrayed in our sample could have more effectively been
documented in a simpler, more clinically relevant manner. Consider the following proposed
revision.
Patient Name: John Doe Date of Service: 05/05/2010
Date of Birth: 01/01/1935
Chief Complaint: Bilateral knee pain
History of Present Illness (HPI):
Mr. Doe is a 75-year-old male with bilateral knee osteoarthritis, last seen six months ago.
Complains of increased pain in both knees over the past month. Rates pain three out of 10
on a 10-point visual analog pain scale. States the pain increased with movement. Relieved
with ibuprofen.
Review of Systems (ROS):
No falls. Denies GI distress, dyspepsia, nausea, blood in stool. No edema.
Past, Family, Social History (PFSH):
Medications:
Ibuprofen 400 mg daily more or less prn pain with fair relief.
Physical exam:
Vital signs – T 98.7, P 76, R 20, BP 130/80.
Musculoskeletal – Bilateral knees with normal range of motion, crepitus on motion, pain with
ambulation rated three out of 10 and tenderness upon palpation.
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Assessment:
Osteoarthritis, knees with occasional joint pain. Discussed therapeutic options of increasing
ibuprofen to routine use vs. prescription medication vs. physical therapy.
Plan:
1. Continue Ibuprofen 400 mg but at every eight hours as needed. Can go to routine use if
needed.
2. Return to office as needed, but return in three months for blood pressure and renal
function check if he begins taking ibuprofen regularly. Will let us know his status in six
weeks.
Dr. Mary Smith
Dr. Mary Smith
Provider Signatures
For the service to be payable, the medical record must have a legible signature from the
rendering provider. This applies to all staff participating in the care of the patient. In the
original documentation sample, no identifier is present to indicate the provider of the service.
In April 2010, CMS issued updated requirements for practitioner signatures. Please refer to
the TrailBlazer job aid, “Documentation Signature Requirements,” for detailed information on
these requirements.
Available Resources and Additional Education
TrailBlazer has several resources to aid in accurate billing of E/M services. The following list
includes a few of the many resources located within the Evaluation and Management
Services specialty services page:
1995 Documentation Guidelines for Evaluation and Management Services.
1997 Documentation Guidelines for Evaluation and Management Services.
CMS Evaluation and Management Services Guide.
Coding and Documentation Pocket Reference.
Documentation Signature Requirements.
http://www.trailblazerhealth.com/Specialty Services/Evaluation and Management
Providers are encouraged to participate in educational opportunities provided by Provider
Outreach and Education to prevent errors in billing. Frequent opportunities include seminars
and workshops, Web-based training sessions and teleconferences. For a list of available
training opportunities or to listen to a previously recorded training event, see the Calendar of
Events Web page: http://www.trailblazerhealth.com/calendar.
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