Documentation Guidelines
For Evaluation and Management Services
I.
Introduction
What
is Documentation and Why Is It Important? Medical record documentation is required to record
pertinent facts, findings, and observations about an
individual’s health history including past and present
illnesses, examinations, tests, treatments, and
outcomes. The medical record chronologically documents that care
of the patient and is an important element contributing
to high quality care. The medical record facilitates:
An appropriately documented medical record can reduce
many of the “hassles” associated with claims
processing and may serve as a legal document to verify the care provided, if necessary. What Do Payers Want and Why? Because payers have a contractual obligation to
enrollees, they may require reasonable documentation
that services are consistent with the insurance coverage
provided. They may request information to validate:
I.
General Principles of Medical Record Documentation
The principles of documentation listed below are
applicable to all types of medical and surgical services
in all settings. For Evaluation and Management (E/M)
services, the nature and amount of physician work and
documentation varies by type of service, place of
service and the patient’s status. The general
principles listed below may be modified to account for
these variable circumstances in providing E/M services. 1. The medical record should be complete and legible. 2. The documentation of each patient encounter should
include:
3. If not documented, the rationale for ordering
diagnostic and other ancillary services should be easily
inferred 4. Past and present diagnoses should be accessible to
the treating and/or consulting physician 5. Appropriate health risk factors should be
identified 6. The patient’s progress, response to and changes
in treatment, and revision of diagnosis should be
documented 7. The CPT and ICD-9-CM codes reported on the
health insurance claim form or billing statement should
be supported by the documentation in the medical record II.
Documentation of E/M Services
This publication provides definitions and
documentation guidelines for the three key components
of E/M services and for visits that consist
predominately COVERAGE/REIMBURSEMENT of counseling or coordination of care. The three key
components:
making-appear in the descriptors for office and other
outpatient services, hospital observation services,
hospital inpatient services, consultations, emergency department services, nursing facility services,
domiciliary care services, and home services. While some
of the text of CPT has been repeated in this
publication, the reader should refer to CPT for the
complete descriptors for E/M services and instructions
for selecting a level of service. Documentation guidelines are identified by the symbol DG. The descriptors for the levels of E/M services
recognize the seven components used in defining the
levels of E/M services. These components are:
The first three of these components (i.e., history,
examination and medical decision making) are the key
components in selecting the level of E/M
services. An exception to this rule is the case of
visits which consist predominantly of counseling or
coordination of care; for these services time is the key
or controlling factor to qualify for a particular level
of E/M service. For certain groups of patients, the recorded
information may vary slightly from that described here.
Specifically, the medical records of infants, children, adolescents and pregnant women may have additional or
modified information recorded in each history and
examination area. As an example, newborn records may include under
history of the present illness (HPI) the details of
mother’s pregnancy and infant’s status at birth;
social history will focus on family structure; family
history will focus on congenital anomalies and
hereditary disorders in the family. In addition,
information on growth and development and/or nutrition will be recorded.
Although not specifically defined in these documentation
guidelines, these patient group variations on history
and examination are appropriate. History of present Illness Review of Systems Past,
Family, and/or Social Type of History (HPI) (ROS)
History (PFSH)
A.
Documentation of History
The levels of E/M services are based on four types of
history (Problem Focused, Expanded Problem Focused,
Detailed, and Comprehensive.) Each type of history
includes some or all of the following elements:
The
extent of history of present illness, review of systems
and past, family and/or social history that is obtained
and documented is dependent upon clinical judgment and
the nature of the presenting problems(s). The chart
below shows the progression of the elements required for
each type of history. To qualify for a given type of
history, all three elements in the table must be met.
(A chief complaint is indicated at all levels.) Documentation Guidelines (DG) DG: The CC, ROS and PFSH may be listed as separate
elements of history, or they may be included in the
description of the history of the present illness. DG: A ROS and/or a PFSH obtained during an earlier
encounter does not need to be rerecorded if there is
evidence that the physician reviewed and updated the
previous information. This may occur when a physician
updates his or her own record or in an institutional setting
or group practice where many physicians use a common
record. The review and update may be documented by:
DG: The ROS and/or PFSH may be recorded by ancillary
staff or on a form completed by the patient. To document
the information was reviewed by the physician, there
must be a notation supplementing or confirming the information recorded by others. DG: If the physician is unable to obtain a history
from the patient or other source, the record should
describe the patient’s condition or other circumstance
that precludes obtaining a history. Definitions and
specific documentation guidelines for each of the
elements of history are listed below. Chief Complaint (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. DG: The medical record should clearly reflect the
chief complaint. 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. It includes the following elements:
Brief and extended HPIs are distinguished by the amount of detail needed to accurately characterize the
clinical problem(s). A brief HPI consists of one to three elements
of the HPI. DG: The medical record should describe one to three
elements of the present illness (HPI). An extended HPI consists of four or more
elements of the HPI. DG: The medical record should describe four or more
elements of the present illness (HPI) or associated
comorbidities. III.
Review of Systems (ROS) A ROS is 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. For purposes of ROS, the following systems are
recognized:
A problem pertinent ROS inquires about
the system directly related to the problem(s) identified
in the HPI. DG: The patient’s positive responses and pertinent
negatives for the system related to the problem should
be documented. An extended ROS inquires about the system
directly related to the problem(s) identified in the HPI
and a limited number of additional systems. DG: The patient’s positive responses and pertinent
negatives for two to nine systems should be documented. A complete ROS inquires about the system(s)
directly related to the problem(s) identified in the HPI
plus all additional body systems. DG: At least ten organ systems must be reviewed. Those
systems with positive or pertinent negative responses
must be individually documented. For the remaining
systems, a notation indicating all other systems are
negative is permissible. In the absence of such a
notation, at least ten systems must be individually documented. IV.
Past, Family and/or Social History (PFSH) The PFSH consists of a review of three areas:
For the categories of subsequent hospital care,
follow-up inpatient consultations and subsequent nursing
facility care, CPT requires only an
“interval” history. It is not necessary to record information about the PFSH. A pertinent PFSH is a review of the
history area(s) directly related to the problem(s)
identified in the HPI. DG: At least one specific item from any of the three
history areas must be documented for a pertinent PFSH. A complete PFSH is a review of two or
all three of the PFSH history areas, depending on the
category of the E/M service. A review of all
three-history areas is required for services that by
their nature include a comprehensive assessment or
reassessment of the patient. A review of two of the three history areas is
sufficient for other services. DG: At least one specific item from two of the three
history areas must be documented for a complete PFSH for
the following categories of E/M services: office or
other outpatient services, established patient;
emergency department; subsequent nursing facility care;
domiciliary care, established patient; and home care
established patient. DG: At least one specific item from each of the three
history areas must be documented for a complete PFSH for
the following categories of E/M services: office or
other outpatient services, new patient; hospital
observation services; hospital inpatient services, initial care;
consultations; comprehensive nursing facility
assessments; domiciliary care, new patient; and home
care, new patient. B. Documentation of Examination The levels of E/M services are based on four types of
examination that are defined as follows:
For purposes of examination, the following body
areas are recognized:
For purposes of examination, the following organ
systems are recognized:
The extent of examinations performed and documented is
dependent upon clinical judgment and the nature of the
presenting problem(s). They range from limited examinations of single body areas to general
multi-system or complete single organ system
examinations. DG: Specific abnormal and relevant negative findings
of the examination of the affected or symptomatic body
area(s) or organ system(s) should be documented. A notation of “abnormal” without elaboration is
insufficient. DG: Abnormal or unexpected findings of the examination
of the unaffected or symptomatic body areas) or organ
system(s) should be described. DG: A brief statement or notation indicating
“negative” or “normal” is sufficient to document normal findings related to unaffected area(s)
or symptomatic organ system(s). DG: The medical record for a general multi-system
examination should include findings about 8 or more of
the 12 organ systems. C. Documentation of the Complexity of Medical Decision
Making The levels of E/M services recognize four types of
medical decision making (straight-forward, low
complexity, moderate complexity and high complexity). Medical decision-making refers to the complexity of
establishing a diagnosis and/or selecting a management
option as measured by:
The chart that follows shows the progression of the
elements required for each level of medical
decision-making. To
qualify for a given type of decision-making, two of the three elements in the table must be either
met or exceeded. Number of Diagnoses or Amount and/or
Complexity Risk of Complications and/or Type of Decision Making
Each of the elements of medical decision-making is
described below. Number of Diagnoses or Management Options The number of possible diagnoses and/or the numberof
management options that must be considered is based on
the number and types of problems addressed during
theencounter, the complexity of establishing a diagnosis
and the management decisions that are made by the
physician. Generally, decision making with respect to a diagnosed
problem is easier than that for an identified but
undiagnosed problem: The number and type of diagnostic
tests employed may be an indicator of the number of
possible diagnoses. Problems, which are improving or
resolving are less complex than those, which are
worsening or failing to change as expected. The need to
seek advice from others is another indicator of
complexity of diagnostic or management problems. DG: For each encounter, an assessment, clinical
impression, or diagnosis should be documented. It may be
explicitly stated or implied in documented decisions
regarding management plans and/or further evaluation. For a presenting problem with an established diagnosis
the record should reflect whether the problem is: a)
improved,
well controlled, resolving or resolved; or, b)
inadequately controlled, worsening, or failing to
change as expected. For a presenting problem without an established
diagnosis, the assessment or clinical impression may be
stated in the form of a differential diagnoses or as “possible,” “probable,” or “role out”
(R/O) diagnoses. DG: The initiation of, or changes in, treatment should
be documented. Treatment includes a wide range of
management options including patient instructions,
nursing instructions, therapies , and medications. DG: If referrals are made, consultations requested or
advice sought, the record should indicate to whom or
where the referral or consultation is made or from whom
the advice is requested. V.
Amount and/or Complexity of Data to Be Reviewed
The amount and complexity of data to be reviewed is
based on the types of diagnostic testing ordered or
reviewed. 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 is an indication of the
complexity of data being reviewed.On occasion, the
physician who ordered a test may personally review the
image, tracing or specimen to supplement information
from the physician who prepared the test report or interpretation; this is another
indication of the complexity of data being reviewed. DG: If a diagnostic service (test or procedure)
isordered, planned, scheduled, or performed at the time
of the E/M encounter, the type of service (e.g., lab or
X-ray) should be documented. DG: The review of lab, radiology and/or other
diagnostic tests should be documented. An entry in a
progress note, such as “WBC elevated” or “chest X-ray unremarkable” is
acceptable. Alternatively, the review may be documented
by initializing and dating the report containing the
test results. DG: A decision to obtain old records or decision to,
obtain-additional-history from the family, caretaker or
other source to supplement that obtained from the
patient should be documented. DG: Relevant findings from the review of old records
and/or the receipt of additional history from the
family, caretaker or other source should be documented.
If there is no relevant information beyond that already
obtained, that fact should be documented. A notation of
“old records reviewed” or “additional history
obtained from family” without elaboration is
insufficient. DG: The results of discussion of laboratory, radiology
or other diagnostic tests with the physician who
performed or interpreted the study should be documented.
DG: The direct visualization and independent
interpretation of an image, tracing or specimen
previously or subsequently interpreted by another
physician should be documented. VI.
Risk of Significant Complications, Morbidity,
and/or Mortality
The risk of significant complications, morbidity, and/
or mortality is based on the risks associated with the
presenting problem(s), the diagnostic procedure(s), and,
the possible management options. DG: 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. DG: If a surgical or invasive diagnostic procedure is
ordered, planned or scheduled at the time of the E/M
encounter, the type of procedure, e.g., laparoscopy, should be documented. DG: If a surgical or invasive diagnostic procedure is
performed at the time of the E/M encounter, the specific
procedure should be documented. DG: The referral for or decision to perform a surgical
or invasive diagnostic procedure on an urgent basis
should be documented or implied. The Table of Risk on the following page may be used to
help determine whether the risk of significant
complications, morbidity, and/or mortality are minimal, low, moderate, or high. Because the determination of
risk is complex and not readily quantifiable, the table
includes common clinical examples rather than absolute
measures of risk. The assessment-of risk of the
presenting problem(s) is based on the risk related to
the disease process anticipated between the present
encounter and the next one. The assessment of risk of selecting diagnostic
procedures and management options is based on the risk
during and immediately following any procedures or
treatment. The highest level of risk in any one category
(presenting problem(s), diagnostic procedure(s), or
management options) determines the overall risk. VII.
Documentation of an Encounter Dominated by
Counseling or Coordination of Care In the case where counseling and/or coordination of
care dominates (more than 50%) of the physician/ patient
and/or family encounter (face-to-face time in the office
or other outpatient setting or floor / unit time in the
hospital or nursing facility), time is considered the
key or controlling factor to qualify for a particular
level of E/M services. 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. TABLE OF RISK
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