Missed Items in E/M Documentation Guidelines
CMS E/M Documentation
Medical record documentation is required to record pertinent facts, findings, and observations about an individual’s health history, including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high-quality care. Because payers have a contractual obligation to enrollees, they may require reasonable documentation that services are consistent with the insurance coverage provided. We have discussed missed items in CMS documentation guidelines for E/M services that are applicable to multiple payers across various states:
CMS Documentation Guidelines for E/M
Missed Items in History
- History is too brief and lacks the reason for the encounter or minimal documentation of the reason for the encounter.
- Documentation for the Review of Systems is too minimal.
- If billing for a Complete Review of Systems – either must individually document ten (10) or more systems OR may document pertinent (some) systems and make the statement in the progress note “all other systems negative.”
- Lacks any documentation in support of why elements of the history or the entire history were unobtainable; it would also apply to document the work done to attempt to obtain a history from sources other than the patient if it was unobtainable from the patient.
- Insufficient documentation of the Past, Family and Social history; no reference to dates or any documentation to support obtaining the information.
- If you wish to refer to a Review of Systems and/or a PFSH documented in a progress note of the previous date and update it with today’s information (e.g., unchanged from ROS of 1/4/07 except patient has stopped smoking) – you must specifically indicate the previous date you are referring to in today’s note and you must include a photocopy of the previous ROS or PFSH you have referred to if you are asked to send documentation for today’s note. Make sure your staff is also aware of this if they will photocopy and send documentation to Medicare.
Missed Items in Physical Exam
- Physical exam documentation is too brief.
- 1997 Specialty exams, billed at the comprehensive level, do not meet all of the required elements for that level.
- For the 1995 Comprehensive exam – required to count ONLY organ systems and not body areas; must be eight (8) or more organ systems only.
- Can choose to perform and document either the 1995 or 1997 physical exam but findings show that most physicians do better with documentation based upon the 1995 guidelines.
Missed Items in Medical Decision Making
- Lack of sufficient evidence that labs, X-rays, etc., were performed to credit in this section (Amount and/or Complexity of Data Reviewed or in Table of Risk of Complications and/or Morbidity or Mortality).
- Lack of sufficient documentation of items which could be credited to Reviewed Data (Amount and/or Complexity of Data Reviewed) such as the decision to obtain old records or obtain a history from someone other than the patient, review, and summarization of old records, discussion of the case with another health care provider.
- Remember, in this section, need only two (2) elements of the three and need only the highest, single item available and appropriate in one box of the chart for Risk of Complications and/or Morbidity or Mortality.
Missed Items in Time-Based Codes
- In choosing a code based upon time for counseling and coordination of care, the total time may be documented but there is not quantification that more than 50 percent of the time was spent on counseling and there is also no documentation of what the coordination of care was or what the counseling was.
- No documentation of time for critical care.
- No documentation of time for discharge day management.
General Missed Items
- Missing the order for a consultation in hospitals and SNFs.
- Illegible documentation.
- Lack of a physician’s signature on the note.
- Missing patient names.
- Incorrect dates of service.
- Lack of any note for a billed date of service.
- Lack of the required two (2) or three (3) key elements to bill an E/M service.
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