Whether performing an audit or providing education, when it comes to evaluation and management (E/M) coding, your first consideration should be accurate, compliant information and results.
Choose Reliable Resources
Our reliable resources are the Centers for Medicare & Medicaid Services (CMS) 1995 and 1997 Documentation Guidelines for Evaluation and Management Services, the Office of Inspector General (OIG) website for compliance guidance, and the CPT® and ICD-9-CM codebooks for specific coding rules. Medicare administrative contractors (MACs) are also good resources for finding information unique to each geographic area.
Why are these recourses so important? If you choose to educate or audit without these stated rules, you’ll impart your opinions in a very crucial area where there is no place for opinions.
Compliance Supersedes Coding
Audits and education for E/M services should go beyond determining the level of service. Many compliance issues can cause the documentation of an E/M service to fail an auditor’s review. The resources noted above will outline key areas where provider documentation will be at risk for non-compliance, even when the level of service is supported by the documentation. When reviewing E/M documentation, remember the items that make the documentation “complete,” as defined by CMS and the OIG.
Focus on Complete Records
Let’s take a look at the areas that continually threaten the completeness of the medical record:
Relevant History: Each record must state the reason for the encounter, any relevant history, and the exam. The chief complaint must be clearly indicated and the relevant history of the condition(s) that warranted the visit must be documented. In other words, the documented history should have some relationship to the reason why the patient is being seen. Too often the history bears no relevancy on the date of service, and instead reads like a past medical history of many problems not addressed at that visit.
Documentation of the History: The only part of the history that may be documented by a nurse, student, ancillary staff, or the patient is the review of systems (ROS) and/or past, family, and social histories (PFSH). The provider (doctor of medicine (MD), doctor of osteopathy (DO), nurse practitioner (NP), physician assistant (PA), etc.) must document the chief complaint and history of the present illness (HPI).
If someone else documents the ROS or PFSH, there must be a notation supplementing or confirming that the provider reviewed the information. If that confirmation is not a part of the record—even if the patient information supports the level of service—the documentation does not meet the compliance rules, and does not count.
Orders for Diagnostic Tests: If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred. This seems simple enough, and yet it can cause many problems. Compliance issues normally arise in paper records more than in electronic records, where orders for diagnostic tests are often linked to a particular diagnosis.
From a compliance standpoint, an auditor must be able to determine that the provider made the decision to order a diagnostic test. Documentation that supports the order provides data when determining the level of medical decision-making. Without documentation showing the provider ordered the test—and even if the test results are documented—an auditor may infer that ancillary staff ordered the test.
Signatures: Per CMS, a signature is “a mark or sign by an individual on a document to signify knowledge, approval, acceptance, or obligation.” This statement does not indicate the signature must be a complete name. In the event of an audit, a provider may provide a signature log to reflect the signature with a typed name. In the instance where a medical record is submitted without a signature, an attestation can be submitted as proof that the provider saw the Medicare beneficiary on that date of service.
Signatures are crucial to validate who saw and participated in the care of the patient. Regardless of the caregiver (e.g., nurse, medical assistant (MA), certified medical assistant (CMA), NP, MD), there must be a signature showing this health professional documented an encounter in the patient’s medical record. Auditors look carefully at who is signing notes and how the notes are signed, which can provide insight into noncompliant practices. Signatures (or the lack of signatures) can reflect who is performing services, versus who is supposed to be performing services.
A good resource for additional signature guidance is your MAC.
Participation of Medical Students: This often comes up in an E/M audit, and goes back to who is allowed to document and perform certain parts of the patient encounter. A medical student may document only the ROS or PFSH, and the provider must confirm that information. Because this is a teaching situation and the student may be asked to take a history and/or perform an exam, as well as document his or her findings, it’s important to understand how that documentation can be used, if at all. The teaching physician must re-perform and re-document his or her own history and exam. Only the work and documentation of the teaching physician will be used for determining the level of service.
Make Sure Guidelines Are Met
When auditing or educating for E/M services, it is crucial to look beyond the level of service to determe if guidelines have been met. Much goes into determining if the medical record is complete. Read the tools and resources and consider each encounter note carefully to determine if the documentation can withstand both coding and compliance audits.
Jaci Johnson, CPC, CPC-H, CEMC, CPMA, CPC-I, is president of Practice Integrity, LLC. She has worked in medical coding and auditing for 24 years and has been a Certified Professional Coder (CPC®) since 1994. Ms. Johnson has expertise in coding for family practice, urgent care, OB/GYN, general surgery, and Medicare’s Teaching Physician Guidelines, with a particular emphasis on E/M guideline compliance. She serves on the AAPC National Advisory Board (NAB), and is past president of her AAPC local chapter. She was also recognized as Virginia’s 2006 Coder of the Year.