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CHAPTER 1
Introduction
Centers for Medicare & Medicaid Services (CMS) provides coders, physicians, and claim reviewers with guidance on acceptable documentation standards for Evaluation and Management (E/M) services. E/M codes were included in the Current Procedural Terminology (CPT) code book in 1992. These codes were designed to classify services provided by physicians during office and hospital visits, skilled nursing facility visits, and consultations. The various levels of the E/M codes describe the amount of effort, time, responsibility, medical knowledge, and decision making that physicians contribute to the prevention, diagnosis, and treatment of medical illness and injuries. Health care facilities, such as hospitals, also report E/M codes to designate encounters where outpatient services were delivered.
In the hospital setting, E/M codes are allocated for emergency department visits. E/M code assignment helps differentiate between medical and surgical services when assigning patients to a specific payment group. E/M code assignment also facilitates data collection for outpatient reporting by counting patients, rather than services. This is important because a patient could have multiple outpatient services during a single visit. Contrary to the documentation guidelines set forth for professional services, facility code assignment is unique to each individual hospital. Under the prospective payment system, CMS directed hospitals to develop their own method for assigning facility E/M codes.
In claims processing for physician services, E/M codes are reported to document the care provided to each individual patient. Although medical necessity is the overarching criterion, code assignment is dependent on the documentation within the medical record.
Documentation guidelines were created to quantify the information needed for each key component. These guidelines provided instruction on the specific documentation requirements necessary to assign E/M codes for the varying levels of service. CMS released the first set of documentation guidelines in 1995.
In October 1997, the Health Care Finance Administration, which is now CMS, and the American Medical Association jointly produced revisions to the 1995 Documentation Guidelines for Evaluation and Management Services.
Although similar in most characteristics, the 1997 guidelines include specific elements that should be performed and documented for general multisystem and single-specialty examinations. Physicians may use whichever set of guidelines is more advantageous, but they must strictly use one or the other, per patient encounter.
For two decades, the 1995 and 1997 guidelines have provided guidance and structure around the documentation requirements necessary to support professional, outpatient services. After 23 years, Medicare has announced the adoption of a new set of standards to be released on January 1, 2021.
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CHAPTER 2
General Principles of Medical Record Documentation
As outlined by CMS, the principles of documentation apply to all types of medical and surgical services, in all settings. For E/M services, the nature and amount of physician work and documentation varies by type of service, patientās status, and the place of service. The standards listed as follows may be modified to account for these varying circumstances in providing E/M services:
ā¢ The medical record shall be complete and legible.
ā¢ The documentation of each patient encounter shall include:
Reason for encounter and relevant history, physical examination findings, and prior diagnostic test results;
Assessment, clinical impression, or diagnosis;
Date and legible identity of the observer.
ā¢ If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.
ā¢ Past and present diagnosis should be accessible to the treating and/or consulting physician.
ā¢ Appropriate health risk factors should be identified.
ā¢ The patientās progress, response to and changes in treatment, and revision of diagnosis should be documented.
ā¢ The CPT and diagnosis codes reported on the health insurance claim form or billing statement should be supported by the documentation within the medical record.
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CHAPTER 3
Classification and Structure of the Evaluation and Management System
The E/M service section of CPT is broken down into broad categories such as hospital visits, office visits, and critical care services. Most of these categories are further divided into two or more subsections of E/M. For example, office visits are split out by new patient and established patient, and there are two subsections of hospital visits: initial and subsequent. These subsections are further classified into levels of E/M services that are recognized by specific codes. This categorization is important as the nature of work varies by place of service, type of service, and the patientās status. The E/M subsections are outlined as follows:
ā¢ Office or Other Outpatient Services
ā¢ Hospital Observation Services
ā¢ Hospital Inpatient Services
ā¢ Consultations
ā¢ Emergency Department Services
ā¢ Critical Care Services
ā¢ Nursing Facility Services
ā¢ Domiciliary, Rest Home, or Custodial Services
ā¢ Domiciliary, Rest Home, or Home Care Plan
ā¢ Oversight Services
ā¢ Home Services
ā¢ Prolonged Services
ā¢ Case Management Services
ā¢ Care Plan Oversight Services
ā¢ Preventive Med...
