Evaluation and Management Documentation Guideline

AccuLibrary

 

SUBJECT: E & M Documentation Guidelines

 

Patient

First name:		Last name:
Date of birth:		Date of service:
Chief complaint:

 

 

Determining Level of E/M Services

(Performance and documentation requirements for key components: History, Examination, and Medical Decision Making)

 

To determine the appropriate level of service for a patient's visit, it is necessary to first determine whether the patient is new or already established. The physician then uses the presenting illness as a guiding factor and his or her clinical judgment about the patient's condition to determine the extent of service to be performed. The key components of this determination are history, examination, and medical decision making.

Instructions: Please make your selection based upon your place of service, whether the patient is new or established, the description that best characterizes the nature of the visit, and the number of key components documented.

 

Office or Other Outpatient Services

New Patient -- Office or Other Outpatient Services (3 of 3 components required)

Established Patient -- Office or Other Outpatient Services (2 of 3 components required)

Initial Observation Care -- Office or Other Outpatient Services (3 of 3 components required)

 

Hospital Inpatient, Observation, or Emergency Department Services

 

Initial Hospital Care (3 of 3 components required)

Consultation -- Reported as Initial Hospital Care (3 of 3 components required)

Subsequent Hospital Care (2 of 3 components required)

Consultation -- Reported as Subsequent Hospital Care (2 of 3 components required)

Observation or Inpatient Care Services -- Including Admission and Discharge (3 of 3 components required)

Emergency Department Services (3 of 3 components required)

 

Nursing Facility Services

 

Initial Nursing Facility Care (3 of 3 components required)

Consultation -- Reported as Initial Nursing Facility Care (3 of 3 components required)

Subsequent Nursing Facility Care (2 of 3 components required)

Consultation -- Reported as Subsequent Nursing Facility Care (2 of 3 components required)

Annual Nursing Facility Assessment (3 of 3 components required)

 

 

Domiciliary, Rest Home, or Custodial Care Services

 

New Patient -- Domiciliary, Rest Home, or Custodial Care Services (3 of 3 components required)

Established Patient -- Domiciliary, Rest Home, or Custodial Care Services (2 of 3 components required)

 

 

Home Care Services

 

New Patient -- Home Care Services (3 of 3 components required)

Established Patient -- Home Care Services (2 of 3 components required)

 

 

History

 

The extent of history of present illness (HPI), review of systems (ROS), and past, family, and/or social history (PFSH) obtained and documented is dependent upon clinical judgment and the nature of the patient’s presenting problem(s).

 

Note: For patient visits requiring an “interval history” (e.g., subsequent hospital, nursing care) a ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded; however, the review of the information should be documented by indicating its status (i.e., description of change(s)/no change to information).

 

HPI

Location

Quality

Severity

Duration

Timing

Context

Modifying Factors

Associated Signs/Symptoms

At least 4 Associated Comorbidities

At least 3 Chronic/Inactive Conditions

 

 

HPI Level (95): N/A

HPI Level (97): N/A

 

 

ROS

 

Constitutional

Eyes

ENT/Mouth

Cardiovascular

Respiratory

Gastrointestinal (GI)

Genitourinary (GU)

Endocrine

Musculoskeletal

Integumentary

Neurological

Psychiatric

Hematologic/Lymphatic

Allergic/Immunological

 

ROS Level: N/A

 

PFSH

 

Past Medical

Family History

Social History

 

PFSH Level:

  

Examination: 1997 E/M Documentation Guidelines

 

A single organ system examination or a general multi-system examination may be performed by any physician regardless of specialty; however, the documentation requirements differ between the two examination types. The depth and type of the examination performed is dependent upon the examiner’s clinical judgment, the patient’s history, and the nature of the presenting problem.

When making each selection, use your cursor to reveal helpful E/M tooltips that are based upon general multi-system examination requirements. Please refer to the tables contained within the 1997 E/M Documentation Guidelines for specific content criteria for single organ system examinations -- including bullet and shaded/unshaded border specifications -- as well as individual examination elements of the applicable body area or system.

 

Body Areas

Head (including face)

Neck

Chest (including breasts and axillae)

Abdomen

Genitalia (including groin and buttocks)

Back

Each extremity

0 Total Body Areas

Organ Systems

 

Constitutional

Eyes

ENT/Mouth

Cardiovascular

Respiratory

Gastrointestinal (GI)

Genitourinary (GU)

Musculoskeletal

Skin

Neurologic

Psychiatric

Hematologic/Lymphatic/Immunologic

 

 

0 Total Organ Systems

 

Single Organ System: Examination Types

 

Problem Focused

Expanded Problem Focused

Detailed

Comprehensive

 

General Multi-System: Examination Types

 

Problem Focused

Expanded Problem Focused

Detailed

Comprehensive

 

Medical Decision Making

 

Medical decision making refers to the level of complexity associated with establishing a diagnosis and/or selecting a management option. The level of complexity is measured by the following factors:

§  The number of possible diagnoses and/or the number of management options that must be considered by the examiner

§  The amount and complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed by the examiner.

§  The risk of significant complications, morbidity, and/or mortality as well as comorbidities associated with the patient’s presenting problem(s), the diagnostic procedure(s) ordered, and/or the possible management options selected by the examiner

  

Number of Diagnoses or Management Options

 

The number of possible diagnoses and/or the number of management options that must be considered is based upon the number and types of problems addressed during the patient visit, the complexity associated with establishing a diagnosis, and the management decisions that are made by the physician. 

 Instructions: For each of the qualifying elements listed below, please enter the number of occurrences that match the criteria specified within the element. For additional guidance, please refer to either the 1995 or 1997 E/M documentation guidelines.

  

Presenting Problem	Occurrences
Self-limited or minor problem(s) -- stable, improving, progressing as expected, or resolved	0
Established diagnosis or diagnoses -- stable, improving, or resolved	0
Established diagnosis or diagnoses -- inadequately-controlled, worsening, or failing to change as expected	0
New problem to examiner -- no diagnostic procedures ordered	0
New problem to examiner -- diagnostic procedure(s) ordered	0
Element Level: None

 

 

Amount and/or Complexity of Data to Be Reviewed

 

The number of possible diagnoses and/or the number of management options that must be considered is based upon the number and types of problems addressed during the encounter, the complexity associated with establishing a diagnosis, and the management decisions that are made by the physician.

 

Instructions: Place a checkmark next to any option that describes services performed and documented during the patient visit. Please select all that apply.

Clinical lab test(s) -- ordered or reviewed

Radiology tests (listed in CPT) -- ordered or reviewed

Other diagnostic tests (listed in CPT) -- ordered or reviewed

Discussion of results with physician who performed or interpreted diagnostic test

Decision to obtain old medical records or history from someone other than the patient

Reporting of relevant findings -- from the discussion of the case with another provider, the review of old medical records, or the review of medical history not obtained from the patient

Direct visualization and independent interpretation of an image, tracing, or specimen (previously or subsequently interpreted by another physician)

 

Element Level: None

 

Risk of Significant Complications, Morbidity, and/or Mortality

The risk of significant complications, morbidity, and/or mortality is based upon the risks associated with the presenting problem(s), the diagnostic procedure(s) ordered, and the management options selected. The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment.

 

Instructions: Because the determination of risk is complex and not readily quantifiable, helpful E/M tooltips have been created to assist you. To reveal each tooltip, place your cursor over each category heading and level selection to display the applicable section of the Table of Risk included within the 1995 and 1997 E/M documentation guidelines.

 

Presenting Problem	Diagnostic Procedure(s) Ordered	Management Options Selected
Minimal	Minimal	Minimal
Low	Low	Low
Moderate	Moderate	Moderate
High	High	High

 

   Note:

 

Most Carriers were instructed to develop in FSY 1995 GUIDELINES FOR E/M SERVICES     

CMS (previously HCFA) developed such guidelines in FSY 1995 and UPDATED FSY 1997.

 

Be advised that most PAYORS are accepting either or GUIDELINES

 

For purpose of the Article the GUIELINES used are:

 

 

1997 DOCUMENTATION GUIDELINES FOR

EVALUATION AND MANAGEMENT SERVICES

 

 

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