The focus on educating providers and coders on the selection of evaluation and management (E&M) services has increased over the years due to numerous factors, including: E&M codes make up the majority of procedures reported by physicians and mid-level providers; audits (e.g. OIG audit focus on E&M especially documentation using EHRs); and the fact that complexity of code selection can be confusing and ambiguous.
Most of the education focuses on the three key components (history, exam, and medical decision making). Proper documentation of these elements is extremely important but we cannot lose focus on the most important criteria for E&M code selection, which is medical necessity. Codes should not be solely selected based on the volume of the documentation of the three key components, but the nature of the patient’s presenting problem and medical intervention required by the provider.
As more and more physicians implement EHRs, there is an increase in the volume of documentation. EHRs are very useful tools if used appropriately, but can be abused to create pages of useless information that does not pertain to the date of service or the patient’s complaint for the encounter. We often see this with the review of systems and past, family, and social history components when elements from a previous encounter are carried forward. When you see the same information documented for the patient each time she is seen, it makes you wonder if the information is obtained each time or a system default. If it is obtained each time, is the information pertinent to the presenting problem?
An effective way to incorporate the focus on medical necessity of the service into your E&M training is to relate it to the provider’s typical patient. When a patient presents to the office, the provider can usually tell quickly how sick the patient is. The patient’s complaint for the day will dictate the questions the provider asks regarding the patient’s presenting problem. This information makes up the history component of the encounter.
Next, the provider examines the patient. The provider should exam all body areas and/or organ systems that are pertinent. Some providers may prefer to perform an eight-system exam for each patient but it might not be medically necessary. For example, a patient presents with an earache. An eight-system exam may not be warranted depending on the last time the patient was seen. If the patient was seen recently for a complete physical and is presenting for only an evaluation of the earache, the complete exam might not be necessary. However, if the patient has not been seen in over a year, the provider will take the opportunity to address the presenting problem(s) and perform a complete exam for preventive measures or conditions the patient may have. Sometimes a patient will present for one problem and “oh by the way” something else is also bothering them.
The medical decision making component includes the provider’s assessment, data collected (e.g. diagnostic tests), and treatment plan. Once the exam is complete, the provider will determine what tests are needed if any. When ordering tests, providers must document the reason for the test. If a definitive diagnosis has not been determined, the reason for the tests will be the patient’s signs and symptoms. Although differential diagnoses are not reported, they should be included in the documentation to support the severity of the patient’s condition.
If the patient is presenting with a headache and the provider is ruling out neurological conditions, it should be included in the documentation. The treatment plan should be documented. It can include medications prescribed, therapies ordered and/or procedures needed.
In addition to using the CMS documentation guidelines for E&M education, incorporate the nature of the presenting problems found in the CPT® E&M coding guidelines. Although the nature of the presenting problem is not one of the three key components, it helps the provider understand the types of conditions that qualify for the different levels of E&M. Focus your education on the patient’s condition, work needed to treat the patient, and the proper documentation to support the services rendered.
Raemarie Jimenez, CPC, CPMA, CPC-I, CANPC, CRHC has over 15 years experience in the medical field. She manages the clinical development of the AAPC exams program. She oversees the development of exam content for all certification exams and exam preparation material such as study guides and practice tests. She assisted with the development of the Medical Coding Training CPC curriculum that is used by PMCC-licensed instructors and the AAPC distance learning course. E-mail her here.