Evaluation and Management (E/M) guidelines are an area of concern for many providers, especially for higher-level visits. CMS’ Comprehensive Error Rate Testing (CERT) Program has also identified E/M as a high error category at a national level. For these reasons, we are publishing the following article as a reminder of the documentation that must be present in the medical record for certain E/M codes and to provide tips to prevent making common errors that we have identified through our review of medical records.

Key Components
The three key components of an E/M visit (History, Examination and Medical Decision Making) determine the CPT code level. Time is a key component only when the visit predominantly consists of (50 percent or more of the visit is comprised of) counseling or coordination of care.

• History (chief complaint, HPI, ROS, PFSH)
• Examination (body areas and/or organ systems for 1995 guidelines; bullet points for 1997 guidelines)
• Medical Decision Making (diagnoses, data, risk)

Coding Guidelines for Level Four and Five Office Visits

• New patient office visits require all three components at the stated level
• Established patient office visits require two of three components at the stated level
• In the chart below, we have used the 1995 and 1997 Examination guidelines. Psychiatrists and Ophthalmologists may find the 1997 E/M Documentation and Coding Guidelines more beneficial. 1997 Eye Exam and Psychiatric Exam guidelines are available in the Physician/Supplier Guide.
• Note: Our medical reviewers utilize both sets of guidelines when evaluating medical records. We select whichever set of guidelines is the most beneficial to the provider in each instance.

• Provide specific and descriptive documentation about what is going on with the patient, and why the patient is seeing you today. Be descriptive enough that someone who had not seen the patient could read the documentation and be well informed of the patient’s condition.
• Notes must be signed and legible. Please keep this in mind if your notes are not dictated.
• Your documentation should indicate the date of service
• Document to the problem and not to the code
• Documentation of all the elements you used, including your judgment, are key to selecting a code

• Review of Systems = Review of 'Symptoms.' If the patient fills out a form for Review of Systems (ROS), make sure that the form asks about symptoms and not diseases. Naming diseases is a history and not ROS.
• The physician must sign / initial / document that he or she reviewed and modified, as appropriate, the ROS information provided by the patient
• Keep in mind that an extended HPI consists of at least four elements of the History of Present Illness (HPI) (location, quality, severity, duration, timing, context, modifying factors, associated signs/symptoms)

• One component of Medical Decision-Making is the number and types of problems addressed during the encounter. If the problem is mentioned but not addressed, this information is considered 'History.'
• When the physician reviews 'old records,' there must be documentation of what the records show. A notation of 'old charts reviewed' is not sufficient.
• Decision-Making is only one element in determining the level of service. A high level of decision-making does not automatically equate to the highest level (code).
• Be sure to review the Table of Risk when assessing the level of risk of the presenting problem (for coding purposes). 'High' would require:
  • Severe exacerbation
  • Injury or illness that would pose threat to life or bodily function (multiple trauma, acute MI, severe respiratory distress)
  • An abrupt change in neurological status

• Time is the key or controlling factor in determining the level of service for visits that consist predominantly (at least 50 percent) of counseling or coordination of care. Medical records must document a description of the coordination of care or counseling provided. In these instances, the time spent with the patient must be documented in the medical record.
• Time spent face to face must be documented in the medical records for all the following 'time-based' CPT codes:
  • CPT code 99239: hospital discharge
  • CPT codes 99291-99292: critical care
  • CPT codes 90804-90815: psychotherapy

Subsequent Hospital Visits:

• If you are unable to obtain a history from the patient or other source, the record should describe the patient’s condition or other circumstance which precludes obtaining a history and the other sources from which you were unable to obtain the history
• A ROS obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. The review and update may be documented by:
  • Describing any new ROS information or noting there has been no change in the information
  • Noting the date and location of the earlier ROS
• Subsequent hospital care requires only an interval history. It is not necessary to record information about the PFSH.
• The chart should contain more information than just 'stable' or 'improving'

• If you make a referral or request a consultation or advice: to whom or where the referral or consultation is made or from whom the advice is requested
• Your review of lab, radiology and/or other diagnostic tests (and results). A simple notation such as 'WBC elevated' is acceptable.
• The results of your discussion of laboratory, radiology or other diagnostic tests with the physician who performed or interpreted the study
• Your direct visualization and independent interpretation of an image, tracing or specimen previously or subsequently interpreted by another physician

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