Three Things E/M Documentation Usually Lacks

Three Things E/M Documentation Usually Lacks

Proper reimbursement hinges on providers telling the whole story of their encounters with patients.

Documentation is key to reimbursement. The more detailed it is, the more likely you’ll receive proper payment for the service it describes. When it comes to evaluation and management services (E/M), every encounter must have a beginning, middle, and end. Unfortunately, providers are not always the best storytellers. That’s where you, the coder, come in.

No. 1History of Present Illness (HPI)

The HPI is the beginning of the story: It sets the background for the patient’s presenting problem, from when it started until this encounter. Often, a provider will fail to document specific details to identify the severity, location, or presenting problem. For example, documentation may state “3 month f/u” or “doing well,” without indicating the condition being addressed.
Let’s look at an example note:
The patient presents today for follow up. Patient seems to be improving and has no new complaints. We’ll plan to see him back in three months.
This note is missing the specific details that aids in supporting medical necessity of this visit. The only element of HPI we could use is quality for the improvement of the patient.
Educating the provider does not have to be a lengthy process: Simply suggest the provider add a few buzzwords to enhance the note. This information is usually obtained, but often isn’t documented in the permanent record.
Let’s look at the same note with a few additional details:
The patient presents today for follow up on his type 2 diabetes. He has had type 2 diabetes for approx. the past 14 years, which was getting out of control. The patient now keeps a diet and exercise log, in addition to the changes in Lantis we made at the last visit. There is an improvement in his blood sugars that he has been recording at home. 
By adding a few pieces of information, the provider has documented a complete HPI, including duration (14 years), severity (type 2 diabetes), modifying factor (Lantis), and quality (improvement in blood sugars).
Like any good story, the HPI must tell the:

  • Who – the patient identifier;
  • What – the chief complaint;
  • When – the duration;
  • Where – the specific location of the presenting problem;
  • Why – the modifying factors, timing, or context; and
  • How – the quality, severity, or signs/symptoms

The point is to find an aid your provider can use to recall and document information that is specific to the presenting problem, as well as supporting the medical necessity of the visit.
Payer rules regarding documentation also factor into the story. For example, here’s a Q&A posted on Wisconsin Physician Services’ (WPS) website:
Q 20. Can the History of Present Illness (HPI) elements be counted for both the Chief Complaint (CC) and the associated signs/symptoms? For instance, a patient presents with chest (location) pain (CC) that she has had for 3 days (duration). She also experiences shortness of breath (associated signs/symptoms) when walking up the stairs (context).
WPS responds, “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 present illness.”

No. 2 Review of Symptoms (ROS)

The ROS can be obtained from a form the patient completes prior to the visit or a conversation between the provider and patient during the encounter. This ROS often is either excessively documented on every encounter or missing in action.
For example, consider this less-than-ideal ROS:
HPI: The patient has complained of a cough for the past three days. She has tried over-the-counter sinus medication, without relief. There are no other complaints at this time.
ROS: As per HPI
The HPI portion of this documentation includes the duration (three days) and modifying factor (over-the-counter sinus medication), but there is not enough information to support the ROS.
Possible solutions: The provider could mention a review of a completed or updated patient history intake form, or document a more in-depth HPI that includes information to support some of the ROS elements.
Too much information can be just as problematic. A good indication a provider is over-documenting is the inclusion of a complete ROS at each visit, regardless of the time interval. Sometimes, providers mistakenly think an electronic health record (EHR) template that includes the entire ROS must be completed to move to the next field.
It’s not appropriate for you to inform the provider that they cannot document a complete ROS. Instead, ask the provider to explain why it’s clinically relevant to obtain a complete ROS in every case. If the provider validates the need, encourage them to include the necessity in the documentation. More likely, the provider will agree that every patient does not warrant a complete ROS at every visit.

No. 3 Assessment and Plan (A/P)

The A/P is the “meat and potatoes” of the note. It should explain what was found; what labs, X-rays, or other services might be ordered or performed; and the expected outcome by the next encounter. Often, in an EHR, this field contains the least amount of information. It may be only a list of diagnosis codes without explanation of severity, medication management, or other important details.
If this part of a provider’s documentation is lacking, perhaps they don’t understand the functionality of the EHR. For example, the assessment area should only be used to list the conditions addressed at the current visit. However, a provider may prefer to see all of the patient’s diagnoses or an ongoing problem list in this area when completing their note. As a result, you may see a list of all current and past chronic conditions in the printed version.
An example of the A/P being used inappropriately might look something like this:
Assessment and Plan:
1. Diabetes
2. Hypertension
3. Osteoporosis
4. S/P CABG 2008
5. Migraines
6. Gout
This is a list of all diagnoses the patient currently has or has experienced. A problem ensues when there is no documented A/P for all of these conditions between this visit and the next encounter.
An accurate and complete A/P includes all conditions addressed at that encounter, or conditions that could affect the treatment of conditions currently being addressed. An example of an accurate A/P looks like this:
Assessment and Plan:
1. Type 1 Diabetes – no changes in medication at this time. Will check A1C in 3 months prior to next visit.
2. Hypertension – stable on Triamterene 37.5 mg, with no changes in dosage.
3. Osteoporosis
4. S/P CABG 2008
5. Migraines – followed by Dr. Smith; current medications are not affecting hypertension.
6. Gout
Conditions 3, 4, and 6 are removed because they are historical information and not currently addressed conditions. Condition 5 is elaborated on to indicate another provider is following it, and that the medication does not have an effect on chronic conditions being treated at this encounter.
The American Academy of Family Physicians offers guidance for when the diagnosis list does not match the order of the submitted diagnosis codes:
Q: Does the order in which diagnoses are listed on the claim matter? Must the order on the encounter form (documentation) match the order on the claim?
Yes, the order does matter. The physician should list on the encounter form the diagnosis (ICD-9) code that is associated with the main reason for the visit. This is the primary diagnosis, and in most cases it should be listed first on the claim form, followed by codes that describe any coexisting conditions that affect patient care, treatment or management. Each diagnosis code should be linked to the service (CPT®) code to which it relates; this helps to establish medical necessity. Any changes to codes or to the order in which they are listed on the claim should be approved by the physician. In some cases, the ICD-9 guidelines may require that certain codes be reordered. For example, the physician may list an ulcer of the ankle first, followed by a related condition such as diabetes. However, because ICD-9 instructs to “Code, if applicable, any causal condition first,” the code for diabetes with other specified manifestations, 250.8X, might need to be listed first, followed by 707.13 for the ulcer.
The same rules hold true for ICD-10: The reason for the visit should be the primary diagnosis, followed by codes for coexisting conditions affecting the care of the patient.


The way providers are paid for their services is gradually changing to a performance-based system, in which documentation is the lifeblood for accurate claims payment. You must inform your providers of any inadequacies in their documentation, but how you communicate this information to them is also important.

  • Respect their time; state information concisely. Ask the provider when it would be a good time to talk, and use less time than scheduled. For example, schedule a 15-minute meeting and finish in 10 minutes. This allows the provider five minutes of down time before their next task.
  • Always use facts. Refer to official source documents and final rules to support your request and methods for documentation improvement.
  • Explain both rewards and risks. 2017 is the proposed start date for the performance period that will determine eligible clinicians’ Merit-based Incentive Payment (MIPS) adjustments in 2019. It will be too late to improve documentation after composite performance scores have been established.

Early education and consistent communication will help to ensure providers are meeting documentation requirements and, ultimately, fully compensated for the care they provide.
American Academy of Family Physicians
Wisconsin Physicians Service Insurance Corporation, J5, History Element of Evaluation and Management Q&As

Brenda Edwards, CPC, CPB, CPMA, CPC-I, CEMC, CRC, has over 25 years’ experience and is senior managing consultant of risk adjustment at Medical Revenue Solutions. Her experience includes chart auditing, coding and compliance education, and writing articles for coding publications. Edwards is an AAPC ICD-10-CM/PCS training expert, and an AAPC workshop presenter. She is a frequent speaker for local chapters and AAPC conferences. She served on the AAPC Chapter Association board of directors from 2010-2014 and held office as chair.

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Brenda Edwards, CPC, CDEO, CPB, CPMA, CPC-I, CEMC, CRC, CPMS, CMCS, CMRS, is executive consultant of risk adjustment at SCBI. She has for over 30 years with experience in chart audit, coding and billing, education, consulting, practice management, and compliance. Edwards shares her expertise writing for Healthcare Business Monthly, as well as other national publications, such as American Academy of Family Physicians (AAFP) and BC Advantage. Edwards helps students obtain their coding credentials through the AAPC Professional Medical Coding Curriculum, and she is an AAPC ICD10-CM/PCS Training Expert. Edwards served on the AAPC Chapter Association Board of Directors from 2010-2014 and held office as chair. She has been involved in the Hardship Fund for AAPC since its inception. Edwards is a mentor and co-founder of the Northeast Kansas (NEKAAPC) AAPC chapter and has served many officer roles.

No Responses to “Three Things E/M Documentation Usually Lacks”

  1. Nihema S. Davis says:

    Great Read – Thank You. I could not have agreed with you more.
    Ms. Davis

  2. Sheri Frost says:

    Great read! Thank you for your input. You are definitely on target!