Evaluation and Management (E&M) Pitfalls to Avoid
Every provider should know the rules for coding evaluation and management (E&M) visits.
Due to the increased audits as a result of the Medicare RAC, now is a good time for a refresher course.
Every patient encounter must include a chief complaint, even inpatient hospital and nursing facility rounding.
If the chief complaint is not documented or easily identifiable in the notes, the service is not billable.
When it comes to history, be careful of over documentation.
Not every office visit requires a detailed or comprehensive history.
If it does, accurate documentation is critical.
The requirements are as follows:
Failure to document one component of the history correctly automatically drops the entire history level.
Example:Failure to document 10 ROS drops to the level of history to Detailed (HPI 4, ROS 9, PFSH 3 = Detailed).
Medical decision-making is defined as the provider's thought process on a quantified basis.
In this case, its acceptable to document ruled-out or suspected diagnoses (just remember its not appropriate to include these for billing) they support the thought process and may increase the level of complexity.
Two of the three medical decision making areas (number of diagnoses, data and risk) must be met or exceeded to reach the specified level of medical decision making.
Data reviewed is an area where a lot of physicians fail to document everything that they do.
Documenting that the chart was reviewed is not enough.
The provider must include comments on what was pertinent from the review.
If that isn't performed and the history is obtained from someone other than the patient, the complexity of the providers medical decision making rises.
For example, a father in the exam room with her 11 year-old provides information that counts in the encounter or a spouse provides additional history during his wife's exam.
If more than 50 percent of the time spent face-to-face with the patient is for counseling or coordination of care, you can use time to determine the appropriate coding for the service.
To document time as the determining factor in what is coded:
Using Medicare as the standard, the documentation requirements are as follows:
The office performing the consultation should maintain the above information in the patient's records as proof is the responsibility of the provider that performs the consultation.
On occasion a provider will encounter an invasive or manipulative procedure that includes some element of an exam to determine whether the patient is healthy and can stand up to the service.
If the evaluation is above and beyond the normal exam, it can be considered "significant, and separately identifiable.
"Such an evaluation should be documented as follows:
Due to the increased audits as a result of the Medicare RAC, now is a good time for a refresher course.
Every patient encounter must include a chief complaint, even inpatient hospital and nursing facility rounding.
If the chief complaint is not documented or easily identifiable in the notes, the service is not billable.
When it comes to history, be careful of over documentation.
Not every office visit requires a detailed or comprehensive history.
If it does, accurate documentation is critical.
The requirements are as follows:
- Detailed history - History of present illness (HPI) 4+, review of system (ROS) 2-9, past family social history (PFSH) 1
- Comprehensive - HPI 4+, ROS 10+, PFSH3
Failure to document one component of the history correctly automatically drops the entire history level.
Example:Failure to document 10 ROS drops to the level of history to Detailed (HPI 4, ROS 9, PFSH 3 = Detailed).
Medical decision-making is defined as the provider's thought process on a quantified basis.
In this case, its acceptable to document ruled-out or suspected diagnoses (just remember its not appropriate to include these for billing) they support the thought process and may increase the level of complexity.
Two of the three medical decision making areas (number of diagnoses, data and risk) must be met or exceeded to reach the specified level of medical decision making.
Data reviewed is an area where a lot of physicians fail to document everything that they do.
Documenting that the chart was reviewed is not enough.
The provider must include comments on what was pertinent from the review.
If that isn't performed and the history is obtained from someone other than the patient, the complexity of the providers medical decision making rises.
For example, a father in the exam room with her 11 year-old provides information that counts in the encounter or a spouse provides additional history during his wife's exam.
If more than 50 percent of the time spent face-to-face with the patient is for counseling or coordination of care, you can use time to determine the appropriate coding for the service.
To document time as the determining factor in what is coded:
- Indicate the total face-to-face time spent with the patient;
- Identify time spent counseling or coordinating care; and
- Provide a detailed description of what was discussed with the patient.
Using Medicare as the standard, the documentation requirements are as follows:
- A request for a consultation from an appropriate source
- The need for the consultation indicated in the patient's chart.
- After the consultation is performed, the consulting physician prepares a written reportof their findings for the requesting physician.
In an office setting, the consultation report should be a separate document that is communicated to the requesting physician.
- Get the request in writing.
If the request is not received in writing, confirm with the referring office the type of service that is being requested. - Request a copy of the patient chart from the requesting provider prior to the patient's arrival, if possible, to confirm that the request is in writing.
- Document the three Rs of the consultation in the record - request from whom, render opinion and respond in writing.
The office performing the consultation should maintain the above information in the patient's records as proof is the responsibility of the provider that performs the consultation.
On occasion a provider will encounter an invasive or manipulative procedure that includes some element of an exam to determine whether the patient is healthy and can stand up to the service.
If the evaluation is above and beyond the normal exam, it can be considered "significant, and separately identifiable.
"Such an evaluation should be documented as follows:
- Make sure to indicate that the note for the E&M services is distinct from the procedure note;
- The E&M service must be greater than the pre-/post-service work for the minor procedure.
