Assessment and Management (E&M) Pitfalls to Avoid

Every provider should know the rules for coding evaluation and management (E&M) visits. Due to the increase in audits as a result of the Medicare RAC, now is a good time for a refresher course.

Each encounter with a patient must include a primary complaint, including the rounding of an inpatient hospital and a nursing facility. If the main complaint is not documented or is not easily identifiable in the notes, the service is not billable.

When it comes to history, beware of excessive documentation. Not all office visits require a detailed or complete history. If so, accurate documentation is critical. The requirements are as follows:

  • Detailed History: Current Disease History (HPI) 4+, System Review (ROS) 2-9, Past Family Social History (PFSH) 1
  • Comprehensive: HPI 4+, ROS 10+, PFSH3

All three elements must meet or exceed the level exactly. If a history component is not properly documented, the entire history level is automatically dropped. Example: Do not document 10 ROS falls to the detailed history level (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, it is acceptable to document the discarded or suspicious diagnoses (just remember that it is not appropriate to include them for billing), as they support the thought process and can increase the level of complexity. Two of the three areas of medical decision-making (number of diagnoses, data, and risk) must be met or exceeded to achieve the specified level of medical decision-making.

The data reviewed is an area in which many doctors do not document everything they do. It is not enough to document that the graph was revised. The provider should include comments on what was relevant about the review. If that is not done and the history is obtained from someone other than the patient, it increases the complexity of medical decision-making by the provider. For example, a father in the exam room with his 11-year-old son provides information that counts in the encounter or a spouse provides additional background during his wife’s exam.

If more than 50 percent of the time you spend face-to-face with the patient is for counseling or care coordination, you can use the time to determine the appropriate coding for the service. Document time as a determining factor of what is encoded:

  • Indicate the total face-to-face time spent with the patient;
  • Identify the time spent advising or coordinating care; and
  • Provide a detailed description of what was discussed with the patient.

There is often confusion behind how to properly document a query. Using Medicare as the standard, the documentation requirements are as follows:

  • A request for consultation from a suitable source.
  • The need for the consultation indicated in the patient’s file.
  • After the consultation is completed, the consulting physician prepares a written report of his findings for the requesting physician. In an office, the consultation report should be a separate document that is communicated to the requesting physician.

To maintain compliance with consultation documentation, physicians must:

  • Get the request in writing. If the request is not received in writing, confirm with the reference office the type of service requested.
  • Request a copy of the patient’s medical record 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 query in the file: ask who, give your opinion and respond in writing.

A written response means a letter back to the requesting physician. The consulting office must maintain the above information in the patient’s records, as testing is the responsibility of the consulting provider.

Sometimes a provider will come across an invasive or manipulative procedure that includes some element of an exam to determine if the patient is healthy and can cope with the service. If the assessment is above and beyond the normal examination, it can be considered “significant and separately identifiable.” Such evaluation must be documented as follows:

  • Be sure to indicate that the note for E&M services is different from the procedure note;
  • The E&M service must be greater than the pre / post service work for the minor procedure.

By ensuring that your practice follows the guidelines above, you can be assured that your providers will receive adequate payment for the services they provide and that no issues will arise should an audit arise.

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