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E&M Auditing. Clarifying Requirements A nd P roviding T ools F or Success Speaker: Marisa Clauson, CPC. Documentation requirements.

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E&M Auditing

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E m auditing

E&M Auditing

Clarifying Requirements And Providing Tools For Success

Speaker: Marisa Clauson, CPC

Documentation requirements

Documentation requirements

  • The first step in understanding medical record documentation is becoming knowledgeable of the Evaluation and Management guidelines by which Physicians and Advanced Practice Professionals must document their services.

Medical necessity

Medical Necessity

“Medical necessity of a service is the overarching criterion

for payment in addition to the individual requirements of a

CPT code. It would not be medically necessary or

appropriate to bill a higher level of evaluation and

management service when a lower level of service is

warranted. The volume of documentation should not be the

primary influence upon which a specific level of service is

billed. Documentation should support the level of service


Per Internet Only Manual (IOM) Medicare Claims Processing

Manual, Publication 100-04, Chapter 12, section 30.6.1

General principles

General principles

Cloned documentation is inappropriate

Cloned Documentation is Inappropriate

Centers for Medicare & Medicaid Services (CMS) contractors have been monitoring supporting documentation of E/M services, and have noticed among EHR users a high volume of records with identical documentation across services. In other words, information from previous encounters is brought forward without updating, which brings into question the validity of the entire service.

Cloned documentation contd

Cloned Documentation-Contd.

Medicare contractors consider records cloned when:

  • Each entry in medical record is worded exactly like or similar to the previous entries.

  • Medical documentation is exactly the same from patient to patient.

  • Cloning often occurs on claims for procedures that have specific sets of coverage criteria and is most often found as pre-printed, template-type and/or electronic health record notes.

  • Medicare contractor position: “Cloning of documentation will be considered misrepresentation of the medical necessity requirement for coverage of services”.

  • What makes this visit different/medically necessary from the previous visit, when both are recorded exactly the same?

1995 vs 1997 documentation guidelines

1995 VS. 1997 Documentation Guidelines

  • Many providers feel that the 1995 guidelines meet their needs more effectively as the documentation requirements aren’t as cumbersome and specific. That being said, the documentation will be less detailed then if the provider were using the 1997 guidelines.

  • Providers can choose to use either the 1997 or the 1995 guidelines, whichever is more advantageous to the provider.

  • It's hard to say that one set of rules is "better" because each version has advantages and disadvantages. You must choose to use one or the other. It is NOT ACCEPTABLE to mix and match elements from both sets of rules within the same note.

Evaluation management services

Evaluation & Management Services

The level of service billed is based on the following three key elements:

  • History

  • Exam

  • Medical Decision Making

    Other contributory components would be:

  • Counseling

  • Coordination of care (with other providers)

  • Nature of presenting problem

  • Time (must be documented in record if used for level of service)

History chief complaint

HISTORY: Chief Complaint

  • Every medical record must document a chief complaint (reason for visit).

  • Usually stated in the patients words

  • Example: Four year old boy complaining of bilateral ear pain, sore throat and fever.

  • Any note not containing a chief complaint will not meet any level of History as it is required for all E&M service levels.

  • The chief complaint does not have to be separately documented from the HPI.

Chief complaint

Chief Complaint

History of present illness hpi

History of Present Illness (HPI)

  • The HPI describes the patients current illness from the first sign and/or symptom to present or from the previous encounter to the present.

  • The HPI must be documented by the provider.

  • There are a total of 8 elements that can be used to describe the HPI.

  • Effective Sept. 30, 2013, when billing Medicare, you may combine the 1997 extended HPI elements along with the 1995 exam guidelines. (Status of 3 or more chronic conditions)

Hpi elements

HPI Elements

Hpi elements cont

HPI Elements, cont.

Review of systems ros

Review of Systems (ROS)

Positive or negative responses to questions that are asked of the patient.

The ROS can be documented by the patient on a questionnaire or by medical staff.

If the provider references this document, he/she would need to document it in the medical record. The provider would also need to date and sign the document to show that it was referenced.

Review of systems

Review of Systems

A total of 14 systems

  • Constitutional Symptoms (usual weight, recent weight changes, fever, weakness, fatigue)

  • Eyes (Visual disturbance, glaucoma, cataracts, pain, redness)

  • Ears, Nose, Mouth, Throat (Hearing, discharge, tinnitus, dizziness, pain, head cold, soreness, redness, hoarseness, difficulty swallowing)

  • Cardiovascular (Chest pain, rheumatic fever, tachycardia, palpitation, elevated blood pressure, edema, faintness, varicose veins)

  • Respiratory (Chest pain, wheezing, cough, dyspnea, bronchitis)

  • Gastrointestinal (Appetite, thirst, nausea,, hematemesis, rectal bleeding, diarrhea, constipation)

Review of systems cont

Review of Systems (cont.)

  • Genitourinary (Urinary Frequency, pain, nocturia, hematuria, incontinence, menstruation changes, symptoms of menopause)

  • Musculoskeletal (Joint of muscle pain, stiffness, cramps, swelling, limitation in motor activity)

  • Integumentary (Rashes, eruptions, dryness, jaundice, changes in skin, hair or nails)

  • Neurological (Headaches, faintness, blackouts, seizures, tingling, tremors, memory loss, involuntary movements)

  • Psychiatric (Personality type, nervousness, mood, insomnia, nightmares, depression)

  • Endocrine (Thyroid trouble, heat or cold intolerance, excessive sweating, thirst, hunger or urination)

  • Hematologic/Lymphatic (Anemia, easy bruising or bleeding, jaundice, transfusions)

  • Allergy/Immunologic (Difficulty breathing, anaphylaxis, swelling, sneezing, runny nose or itchy eyes in response to food, medication or airborne allergens)

Three levels of review of systems

Three Levels of Review of Systems

Pfsh past family social history

PFSH - Past, Family & Social History

What is your history level

What is your History Level?

All three elements in the table must be met to qualify for a given type of history.

DO NOT count a given element more than once in determining a type of history. For example, an element counted in the HPI may not be counted again as an element of the ROS.

Review of system MUST be medically necessary for chief complaint. If patient presents for a ankle sprain you should not be checking the Genitourinary system!

What level of history is this

What level of history is this??

10 year old boy presents today complaining of right wrist pain. He indicates that he was skate boarding yesterday and fell. Feels sharp pain when he grabs at objects. Mom indicates that Tylenol does seem to help a little.

Review of system: Patient states wrist hurts with movement.

No PFSH documented.

Code my level of history

Code my level of history….

4 HPI Documented

  • Location- Right Wrist pain

  • Duration- Fell yesterday

  • Quality- Sharp pain

  • Modifying Factors- Tylenol helps a little

    1 Review of Systems

  • Musculoskeletal

    No Past, Family or Social History

    History= Expanded Problem Focused

Exam systems

Exam Systems

  • Constitutional (Vital signs, general appearance)

  • Eyes

  • Ears, nose throat & mouth ( When auditing, verify all 3 areas are documented to give credit)

  • Cardiovascular

  • Respiratory

  • Gastrointestinal

  • Genitourinary

  • Musculoskeletal

  • Skin

  • Neurologic

  • Psychiatric

  • Hematologic, lymphatic, immunologic

Levels of e m services

Levels of E&M Services

Based on four types of exams, using 1995 Guidelines

  • Problem Focused- A limited examination of the affected body area or organ system

  • Expanded Problem Focused- A limited examination of the affected body area or organ system and other symptomatic or related organ system(s)

  • Detailed- An extended examination of the affected body(s) and other symptomatic or related organ system(s)

  • Comprehensive- A general multi-System examination or complete examination of a single organ system(s)



  • An examination may involve several organ systems or a single organ system. The type and extent of the examination performed is based upon clinical judgment, the patient’s history, and nature of the presenting problem(s).

  • The 1995 documentation guidelines describe two types of comprehensive examinations that can be performed during a patient’s visit: general multi-system examination and single organ examination.

  • 1997 Guidelines - A general multi-system examination involves the examination of one or more organ systems or body areas, as depicted in the chart on the next slide.

E m auditing

1997 Guidelines:

A single organ system examination involves a more extensive examination of a specific organ system, as depicted in the chart below

E m auditing

A single organ system examination involves a more extensive examination of a specific organ system, as depicted in the chart below.

What level is your exam

What level is your Exam?



Documentation of an Encounter Dominated by Counseling and/or Coordination of Care

  • When counseling and/or coordination of care dominates (more than 50 percent of) the physician/patient and/or family encounter (face-to-face time in the office or other outpatient setting, floor/unit time in the hospital, or NF), time is considered the key or controlling factor to qualify for a particular level of E/M services. If the level of service is reported based on counseling and/or coordination of care, the total length of time of the encounter should be documented and the record should describe the counseling and/or activities to coordinate care.

  • The Level I and Level II CPT® books, which are available from the American Medical Association, list average time guidelines for a variety of E/M services. These times include work done before, during, and after the encounter. The specific times expressed in the code descriptors are averages and, therefore, represent a range of times that may be higher or lower depending on actual clinical circumstances.

Medical decision making

Medical Decision Making

Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option, which is determined by considering the following factors:

  • The number of possible diagnoses and/or the number of management options that must be considered;

  • The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed; and

  • The risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the patient’s presenting problem(s), the diagnostic procedure(s), and/or the possible management options.

E m auditing

The chart below depicts the elements for each level of medical decision making. To qualify for a given type of medical decision making, two of the three elements must either be met or exceeded.

Number of diagnoses and or management options

Number of Diagnoses and/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

    In general, decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem. The number and type of diagnosed tests performed may be an indicator of the number of possible diagnoses. Problems that are improving or resolving are less complex than those problems that are worsening or failing to change as expected. Another indicator of the complexity of diagnostic or management problems is the need to seek advice from other health care professionals.

E m auditing


Amount and or complexity of data to be reviewed

Amount and/or Complexity of Data to be Reviewed

The amount and/or complexity of data to be reviewed is based on the types of diagnostic testing ordered or reviewed. Indications of the amount and/or complexity of data being reviewed include:

  • 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 (indicates the complexity of data to be reviewed); and

  • The physician who ordered a test personally reviews the image, tracing, or specimen to supplement information from the physician who prepared the test report or interpretation (indicates the complexity of data to be reviewed).

Complexity of data cont

Complexity of Data, Cont.

  • Relevant findings from the review of old records and/or the receipt of additional history from the family, caretaker, or other source to supplement information obtained from the patient should be documented. If there is no relevant information beyond that already obtained, this fact should be documented. A notation of “Old records reviewed” or “Additional history obtained from family” without elaboration is not sufficient.

  • Discussion about results 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

Risk of Significant Complications, Morbidity, and/or Mortality

Medical decision making1

Medical Decision Making

Some important points that should be kept in mind when documenting level of risk are

Some important points that should be kept in mind when documenting level of risk are:

  • 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, performed or scheduled at the time of the E/M encounter, the type of 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

E m auditing

Risk of Significant Complications, Morbidity, and/or Mortality, cont.

The table on the next couple of pages may be used to assist in determining whether the level of risk of significant complications, morbidity, and/or mortality is minimal, low, moderate, or high. Because determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk.

New vs established pts

New vs Established pts

  • No face-to-face professional services received from the physician or another physician of the same specialty and sub-specialty who belongs to same group practice for three years

  • Internal Medicine and Family Practice are considered different specialty

  • Patient seen by physician covering or on-call physician considered patient of usual doctor and is not a new patient

Putting it together

Putting it together



DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services (Evaluation and Management Services Guide)

“The Art of E&M Auditing” by Intelicode

Per Internet Only Manual (IOM) Medicare Claims Processing

Manual, Publication 100-04, Chapter 12, section 30.6.1

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