2 out of 3 in E/M


White Plains, NY
Best answers
I have a provider who documents only two of the three key components for extablished patients, because only two of the three are required to assign the E/M. The result is no CC (just follow-up), HPI, ROS or PFSH.

Is this code-able at all?


Hi, Lin, while we wait for help from the seasoned veterans on here (many are in Jacksonville), thought I’d offer a few thoughts, but I’m shakey in EM, so that is my disclaimer, and answers are based on what I learned in school.

Doctor must indicate that patient is in for followup for __________? WHAT specifically is he being seen for?

And if he has no specified CC, medical necessity crumbles, hence not being codeable from what I understand in my training.

Furthermore, IF all he has is HPI, ROS and PFSH, these three factors together = only ONE component of the requirements for an EP. EXAM and MDM are both missing, therefore he only has 1/3 which is poor documentation and would be non-codeable unless there’s a new modifier for “incomplete!” IMO. (see disclaimer again).

---Suzanne E Byrum, CPC
The documentation guidelines state that a "Chief complaint is indicated at all levels". Although the established office visits (for example) only require 2 out of 3, medical necessity becomes an issue when there is lack of documentation as to why the patient is being seen. The "CC" is the reason for the visit. It would be hard to justify a detailed exam (for example) when it hasn't been established why the patient is being seen.

Additionally, my carrier frowns on "follow up" as the recorded "CC".

"Indicate clearly the chief complaint and/or reason for the visit. Don't limit the chief complaint to "follow-up" without identifying the problem(s) being followed."

If I couldn't pull the "CC" from somewhere within the note (some providers dictate one long paragraph), I would re-educate the physician.
CC, HPI, ROS and PFSH are all needed for the history portion of the E/M code. If there is no history documented, then the claim is unbillable for lack of documentation, or at least it would be in my office.
Thanks to all of you.
I pretty much agree. What happens is that the CC is called follow-up, with no HPI, PFSH or ROS, and then some other little problem is "discovered" in a problem limited exam, "justifying" the E/M code along with the procedure. As this is a dermatologist, it seems that you can always find some little do-dad to remove.
Perhaps someone with deep experience who is at the conference will chime in - or I might post again next week when everyone's back.

Thanks again