E/M Documentation


Best answers
I have a new provider trying to document a certain way which I can agree and disagree, can someone help to determine if this is valid documentation. This a specialty dermatology provider who is trying to just sum up everything really short. His format is not like other providers where you format HPI,EXAM, and MDM. Help!

Face: few papules
-clindamycin lotion has helped with dryness
-not sure if doxycycline pills helped condition
-Elidel will help with redness and inflammation
            -use with clindamycin lotion

-v shaped rash to chest, papules
-x 4 months; red and irritated
-history of seasonal allergies
-takes claritin for relief
-apply cream prescription to chest
-We suggest using zyrtec (certirizine) pills

Irritated Seborrheic Keratosis
0.4 centimeters papules
-under breasts
-mammo scheduled for May - treatment will be deferred until then

Post removal of Irritated Seborrheic Keratosis - left upper breast - healing well - no discomfort now
Smooth scar
No treatment


True Blue
Best answers
While E/M coding for outpatient is no longer determined by HPI or exam (only MDM), this documentation leaves something to be desired. Specifically:
1) It's very difficult to determine the complexity of problems when you don't know more of the story.
2) Regarding medications, it's not clear what was prescribed (cream prescription?), who prescribed, etc.
The theory of the 2021 outpatient E/M changes was to reduce unnecessary administrative burden, and allow the MDM (clinician judgement which is why you see a physician in the first place) to drive levels. However, if the MDM is taking place only the clinician's head and not being adequately demonstrated on paper, you will wind up with very low levels. I know extent of history is whatever the clinician determined, but I can't imagine for a patient with a rash, that they weren't asked if they are using any new lotions, creams, soaps, detergents, medications, etc. I am guessing there is more interaction between the patient and clinician than these examples provide, but you can't code what is not documented.