Documentation Requirements for Components of E/M

KStaten

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Hello Everyone!

With the new 2021 E/M Documentation changes, there have been questions that have arisen in regards to requirements for the HPI and Exam. Now that these components are deemed "medically appropriate" by the provider, that leads some to think that the extra the flexibility extends into the other aspects of these components.

To my understanding, the following are true:
1) The HPI may still be documented by the ancillary staff, but the exam MUST still be documented by the provider (or scribe on his / her behalf) who is treating the patient for that visit (physician, PA, NP, etc). (?)
2) Though the documentation requirements have been reduced, both of these components (the HPI and the exam) are still required for a complete note. (?)

Am I correct? (It won't be the first or last time I have been wrong ;)

Thank you in advance,
Kim


 

Cheezum51

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You still need to have the medically appropriate history and exam, which have to be recorded properly to show medical necessity and what problems were addressed during the exam. To my knowledge, the HPI and ROS still have to have a note that the provider reviewed them and the provider still has to sign the exam record.

Tom Cheezum, OD, CPC, COPC
 

Orthocoderpgu

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The documentation requirements have not been "reduced". The ROS/EXAM still need to be documented, nothing has changed other than these are now not used to determine the E/M level. I've been in this business for 20 years and this aspect is a good change simply because the doctor can now focus on documenting the relevant History & Exam, rather than doing more than is medically necessary just to get a higher E/M level. I audited one clinic and found out that EVERY patient, no matter what, had a "Comprehensive" HPI/ROS. Is this "medically necessary"? Of course not. The docs just knew that the more they documented, the higher the E/M level they could bill. Under 2021 I can only hope that we can get away from the "Over Documentation" syndrome that has plagued us since 1995.
 

fwnewbie

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The documentation requirements have not been "reduced". The ROS/EXAM still need to be documented, nothing has changed other than these are now not used to determine the E/M level. I've been in this business for 20 years and this aspect is a good change simply because the doctor can now focus on documenting the relevant History & Exam, rather than doing more than is medically necessary just to get a higher E/M level. I audited one clinic and found out that EVERY patient, no matter what, had a "Comprehensive" HPI/ROS. Is this "medically necessary"? Of course not. The docs just knew that the more they documented, the higher the E/M level they could bill. Under 2021 I can only hope that we can get away from the "Over Documentation" syndrome that has plagued us since 1995.
Aha! I've been in a turmoil over this very point - doctors making a note on 10 body systems for every OV, even if the system has nothing to do with the complaint.
My most recent experience as a patient has been when I review the visit notes in the computer, I noticed items were documented but not done: example: Documented: no carotid bruit; bowel sounds normal; pedal pulses 2+, and the list goes on. None of these exams were actually done by the NP or LPN in the room and were not needed to assess cellulitis due to insect sting. So that led me to believe this must be the standard check-list style H&P and this stuff gets clicked whether it's done or not. BTW: I saw this on another family members chart with more stuff documented than I actually saw done.
I have no education in provider coding but this has to be fraudulent medical care, but what they don't know is it doesn't have anything to do with getting higher reimbursement! lol
 

KStaten

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The documentation requirements have not been "reduced". The ROS/EXAM still need to be documented, nothing has changed other than these are now not used to determine the E/M level. I've been in this business for 20 years and this aspect is a good change simply because the doctor can now focus on documenting the relevant History & Exam, rather than doing more than is medically necessary just to get a higher E/M level. I audited one clinic and found out that EVERY patient, no matter what, had a "Comprehensive" HPI/ROS. Is this "medically necessary"? Of course not. The docs just knew that the more they documented, the higher the E/M level they could bill. Under 2021 I can only hope that we can get away from the "Over Documentation" syndrome that has plagued us since 1995.
Yes, I agree that there can be "over-documentation," as previous requirements encouraged being "rewarded" for offering unnecessary information. As unethical as that may be, it does happen in certain offices. As a patient, I remember a doctor failing to diagnose an obvious fracture after barely examining my left hand and dismissing his own technician's x-ray findings, yet he wrongfully documented that he examined multiple body systems and both arms. Granted, with that said, I do see the need for adequately detailed documentation for continuity of patient care... as well as for justification for medical necessity and protection against false malpractice claims. As with everything, there has to be a balance. :)
 

KStaten

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You still need to have the medically appropriate history and exam, which have to be recorded properly to show medical necessity and what problems were addressed during the exam. To my knowledge, the HPI and ROS still have to have a note that the provider reviewed them and the provider still has to sign the exam record.

Tom Cheezum, OD, CPC, COPC
Thank you, Tom, for your reply. :) I have heard arguments on both side as to whether or not the doctor has to note that he/she has reviewed the information entered in HPI and ROS. From what I have read, I have thought that, as you had stated, the doctors must add a statement to verify that they had reviewed it. However, I have been told that a final signature is equivalent to/ sufficient for "verifying" that the information has been reviewed, whereas, in order to add the final signature on the document in its completion, ultimately, the doctor must first review ALL information that has been documented. The argument for that case is that the statement would be redundant, since the final signature applies to (and verifies) everything in the note. (The only exception in that scenario, is if the doctor makes any changes to what had been documented by other staff.) Has anyone else heard that? :unsure: Thanks!
 

thomas7331

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The stated purpose of the revisions to the E&M guidelines is to reduce the administrative documentation burden on these services. So as I understand it, the whole reason behind changing the wording to state that the record should include a "medically appropriate history and exam" is that it should be entirely up to the clinical judgment of the provider as to what they should or should not include in these sections of the note. It defeats the purpose of these revisions completely if you're going to have coders start telling providers how they need to document their history or exam again. So, for example, whether or not the provider states that they reviewed the ROS for this particular encounter is up to them - if they didn't feel a need to review it, then that's of no concern to the coder.

So I think a coder does not need to be concerned with this if they are auditing strictly from a coding quality standpoint as it has no bearing on code selection. If you are conducting an audit for clinical documentation improvement or patient care quality purposes, then it might make sense to give feedback about clinically important information that was omitted from the record and should be included. But from a coding perspective there's no need to be placing any of these requirements back on the providers.
 
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Cheezum51

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thomas7331, I understand your points and they are valid. I guess when I made the comment about the provider needing to acknowledge review of any HPI and ROS taken for an exam is because both may have been taken and recorded by staff members. A couple of years ago, asked a person who did formal Medicare audits what they checked during the audits. The person mentioned that one of the first things they looked at was whether the ROS and medications lists for a patient coincided with each other. The auditor said they often found dramatic differences in the two. For example, the ROS would say that cardiovascular and endocrine were normal but the medication list would show several medications for cardiac problems and diabetic meds. To the auditor, this showed that the provider didn't really review the ROS, despite stating they had in the record, which could possibly cause an audit failure if this was a consistent problem.

Therefore, since I hadn't read anything saying those HPI and ROS acknowledgements were no longer in effect, I assumed they were.

It would be interesting to hear what someone who is doing auditing now would think of this.
 
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