Wiki Help with E/M Documentation Question

[tinaleslie]

I have a hospital provider that completes a separate chart for an initial visit but has started listing a summary of each subsequent visit under the date of the discharge. He gives a short summary and a little decision making. When I review the charts I am seeing it a a summary of each day. Not a visit.
There are no exams with these. The CPT guidelines state, "E/M codes that have levels of services include a medically appropriate history and/or physical examination, when performed." I interpret that it doesn't necessarily have to have an exam. But does each chart have to stand alone with date and signature or can he do a running summary of each day on one chart.

Example looks like this

1/10/23
Seen today on dialysis
-Patient to start regular physical.
-asymptomatic
-Awaiting for cardiology/EP consult eval
-Awaiting podiatry consut
-Awaiting for diabetic educator eval
-No chest pain or trouble breating
-No nausea or vomiting
-Foley catheter removed
-No trouble with urination

1/11/23
-Complains of nausea
-Has diarrhea
-ad dialysis last night
-No trouble with urination after Foley catheter removal
-On MiraLax as needed
-Not seen yet by EP and will put an order for second request
-Seen by podiatry and they will clip tonails hopefully today
-During writng my note I was called by his nurse that his diarrhea smelled like C.diff and will collect stool for C.dfficile PCR
-also we may get GI panel, second request


Its a running note. Can they be billed separately? (I am stating no, but change my mind?)

 

[kayleeevans907]

Just from the info here I'm inclined to say no.
I can't identify what the patient is presenting for or what the provider is assessing/treating in the first note (1/10/23). The second note I could pull nausea & diarrhea as dx codes and see that they're using OTC meds (miralax) for treatment so based on that I guess you could try to use MDM but I dislike that there isn't much specifically about the condition in relation to the patient (how long has the nausea & diarrhea been present? is it made better/worse by anything?).

 

[jkyles]

Hi there, it's true that history/exam aren't required under the new guidelines, but the note - and coding - for each visit must stand on its own. Perhaps you could give a couple of the summaries to a supervisor and ask them if they could code the service? The provider might also need some training on the new guidelines.

 

[podcoder70]

Oh goodness. These notes would not pass an audit in my opinion. Since 1992, a visit level was based on a combination of history, physical exam, and medical decision-making elements. Beginning in 2023, the E/M services are based only on medical decision making.
While its true that ROS and PE documentation do not add to the e&m code level, a medically appropriate history and physical exam is still required in most cases. The MDM is what drives the e&m level choice. The MDM elements associated with e&m management services consist of 3 components, 1. problem: the number and complexity of problems addressed, 2. Data: amount and/or complexity of data to be reviewed and analyzed, 3. Risk: risk of complications and/or morbidity or mortality of patient management.
In the examples provided, not only is there no PE but there is also very little MDM documented and the number and complexity of problems is lacking. One could argue that in the note from 1/10 there was a PE in stating no CP/NV and one could argue that the doctor ordered PT...but it is unclear that these things were done due to the limited wording. The second note has minimal subjective, no PE and one order for stool. The new e&m rules have eliminated the need for all of the "bullet" points to get to the appropriate code level, however, what the new rules did not do is eliminate the need for quality medical treatment.
The AMA has guidance on e&m documentation, I attached the info.