5 Focus Areas to Improve E/M Documentation and Reimbursement

Evaluation and management (E/M) services comprise a significant portion of most providers’ billable services. To ensure coding (and reimbursement) reaches optimal levels, providers must be careful to document services carefully. Here are five common problem areas to watch for.
1. Legibility
When it comes to coding, two fundamental rules are “Not documented, not done,” and “You can’t code what you can’t read.”
Per CMS requirements, “All entries in the medical record must be legible. Orders, progress notes, nursing notes, or other entries in the medical record that are not legible may be misread or misinterpreted and may lead to medical errors or other adverse patient events.”
Best practice is for the provider office to adopt a legibility standard within its compliance program.
2. Documenting Orders
The provider who is treating the patient must order all diagnostic X-ray, laboratory, and other diagnostic tests. The treating provider is “The physician who furnishes a consultation or treats a patient for a specific medical problem and who uses the results in the management of the patient’s specific medical problem,” as stated in 42 CFR 410.32. An order, as defined in the Medicare Benefit Policy Manual is, “A communication from the treating physician/practitioner requesting that a diagnostic test be performed for a beneficiary.” Tests not ordered by the treating physician/practitioner are not reasonable and necessary.
Best practice is for the provider office to create a template for commonly ordered diagnostic tests, keeping in mind that the template used for ordering tests must be validated with the ordering provider’s signature, rather than ancillary staff.
3. The Provider Must Record the HPI
The CPT® codebook explains that the three key components of an E/M service are history, exam, and medical decision-making (MDM). History is composed of the chief complaint (CC), history of present illness (HPI), review of systems (ROS), and past, family, and social history (PFSH). Both the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services clarify which part of the medical record the ancillary staff may document: “The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation, supplementing or confirming the information recorded by others.”
Best practice is for the provider to document the CC, HPI, examination, and MDM. Ancillary staff should document only the ROS and PFSH, if the physician/practitioner prefers them to do so.
4. Consider Patient Status, All Relevant Key Components
The first step in selecting the code is for the physician to determine if the patient is new or established. According to the CPT® codebook, “A new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years. An established patient is one who has received professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past three years.”
When selecting a level of care for a new patient, note that all three key components are required for proper coded selection. Established patient codes require two of the three key components. Best practice is to always document the “standard of care” for the nature of the presenting problem, and to select the code that appropriately represents the services rendered and documented.
When counseling and/or coordination of care make up greater than 50 percent of the face-to-face time of the encounter, time can be the controlling factor to determine the E/M service level. Documentation requirements for coding by time include:
a) Total time (face-to-face) of the visit
b) Total time of the counseling and coordination of care
c) Substance of the counseling and coordination of care
5. Diagnoses
Always document and code to the highest diagnostic specificity for the services rendered. Per the 1995 and 1997 Documentation Guidelines, “To reduce many of the ‘hassles’ associated with claims processing and may serve as a legal document to verify the care provided, if necessary … The CPT and ICD-9-CM codes reported on the health insurance claim form statement should be supported by the documentation in the medical record.”
The ICD-9-CM manual describes guidelines for outpatient/office visit diagnosis coding, as follows:

• Diagnosis and procedure codes should be reported to the highest number of digits available (highest degree of certainty) for the encounter/visit.
• List first the ICD-9-CM code for the diagnosis, condition, problem, or other reason for the encounter/visit shown in the medical record to be chiefly responsible for the services provided.
• Do not code diagnoses documented as “probable,” “suspected,” “questionable,” “rule out,” or “working diagnosis,” or other similar terms indicating uncertainty.
• Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management.
• Do not code conditions that were previously treated and no longer exist.

Look for Diagnostic Coding and Reporting Guidelines for Outpatient Services in the ICD-9-CM manual, Coding Guidelines (Section IV). Always sequence diagnoses in the proper order, beginning with the problem/condition chiefly responsible for the patient encounter, followed by secondary problems/conditions relevant to the services rendered and not already described by the primary diagnosis.

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John Verhovshek

John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

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