Wiki E/M documentation


Ankeny, IA
Best answers
Was wondering if any one new of any regulation in regards to documentation. The question at hand is this, can a physician make one big circle around all WNL in the examination portion? Does the physician have to physicially circle each individual one. Also, what about drawing a line through all. How individualize does it have to be?

How nit pickey will a payor be? Has anyone run into this with payers?
Circles or lines?

My training was that only on the ROS could the physician (or patient, for that matter) rely on circling or checking the box, etc.
The PE had the various systems headings, but the physician had to write his/her findings in his/her own hand (or dictate). Circling WNL would not give you any bullet points on my audit tool.
F Tessa Bartels, CPC-E/M
It is my understanding that CMS will give you credit for using things like check boxes in any area of the E/M - but be careful, abnormal findings require further explanation. They have stated, however, that you may not draw a single line through multiple boxes.

Of course, I can't find the resource for that at the moment, but I have seen it....
Those individual check boxes are there for a reason, and I would advise against using one circle around all of them to indicate all of them are checked. Some payers are VERY nit pickey and WILL reduce E/M charges due to insufficient documentation in an audit, years after the service date. They will, and do, reduce the charges to what they deem to be appropriate. Shortcuts are very tempting, but cost in the end.
-Bill Hale, CPC
makes no difference what they do on that sheet IF it isn't supported in the documentation! I agree with halebill though, the boxes are there for a reason. Our providers do not mark any boxes or such - they don't use an E/M scoring tool - we, as coders use them when we're auditing their documentation/dictation for support of their charges. :)
I agree with the postings. I do agree with Colleen that CMS allows check off forms. I can't recollect where I saw this but I know that credit is given unless it's not clear what the provider's intention is. In that case, the provider would have to appeal any adverse decision made regarding the review and provide an explanation.