Secure the Correct E/M History Level -- Every Time
Published on Wed Jul 18, 2007
Auditors are watching, but these tips keep you in the clear If choosing E/M patient history levels leaves you in a daze, slow down and take a look at this element-by-element breakdown. Then use our handy chart to be sure you-ve met every requirement your payer demands.
Reality: E/Ms are the easiest for regulators to audit, says Bill Dacey, MHA, MBA, CPC, in his presentation -E/M Auditing: Regulations vs. Reality- at the 2007 national American Academy of Professional Coders conference in Seattle.
One important aspect of selecting the proper E/M code is pinpointing the right history level.
You have four history levels to choose from for your E/M coding:
- problem-focused
- expanded problem-focused
- detailed
- comprehensive. When determining the appropriate history level for your E/M codes, consider the following elements.
Remember: Carriers believe that even when the provider generates a complete note, you can't choose a code based on information not relevant to the patient's condition, Dacey says.
Always Require a Chief Complaint Chief compliant (CC): Every E/M history level requires a chief complaint, says Missouri-based coding consultant Sandra Soerries, CPC, CPC-H. According to the CPT manual, this is a concise statement, usually in the patient's words, explaining the main reason for the appointment. Look for a symptom, problem, condition or diagnosis.
Example: A patient presents between chemotherapy treatments and complains of nausea.
-Without a chief complaint, you don't have medical necessity,- Soerries says. Look for documentation of specific problems. Even if the patient is returning at your office's request, look for the complaint that prompted the visit, Soerries says.
Bottom line: Look for a complete CC. Payers won't find -Here for recheck- an acceptable chief complaint. Look for These Factors in Patient Timeline History of present illness (HPI): HPI should be an actual chronological description of the patient's current illness, Dacey says.
Look for location (example: lung), quality (example: dull pain), severity (example: limited disease process), duration (example: tumor detected last month), timing (example: soon after taking the medication), context (example: while walking quickly), modifying factors (example: better after sleeping), and associated signs and symptoms (example: nausea).
If you have documentation of one to three of these categories, consider this a brief HPI. Four or more equals an extended HPI. Divide ROS Into 3 Categories Review of systems (ROS): For this requirement, the provider either analyzes a questionnaire filled out by the patient or support staff or directly asks the patient questions (or both). This section does not involve examining or touching the patient.
If documentation covers only the system directly related to the present illness, consider this a problem-pertinent ROS.
Inquiring about the most directly related system as well as a limited number of others (for a total of two to nine) is an extended ROS, Soerries says.
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