When billing for an office visit, you can choose to use Evaluation and Management (E&M) codes (99XXX) or Eye visit codes (92XXX). This article highlights recent changes to the documentation requirements for E&M codes. (Note: CMS plans sweeping changes to E&M codes in 2021. To keep track of the latest developments, check your email each week for Washington Report Express and, if you are an AAOE member, Practice Management Express.)
Three Changes to How You Document E&M Codes
Less redundancy when staff or the beneficiary have documented the chief complaint. Effective Jan. 1, 2019: For E&M codes, new CMS rules state that physicians don’t have to “re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary.” Instead, physicians should indicate that they have reviewed and verified this information. This new policy applies to both new and established patients.
This change is optional. CMS states that you can continue your earlier documentation processes. (Source: Federal Register 83:59635.)
Less documentation for home visits. Effective Jan. 1, 2019: If you use the E&M codes for home visits (99341-99350), you no longer have to document the medical necessity for furnishing the service at the home rather than at the office or as an outpatient visit. CMS notes that the patient doesn’t have to be confined to the home in order to be eligible for such a visit. (Source: Federal Register 83:59630.)
Less documentation for teaching physicians. Effective Aug. 14, 2018: Physicians may review, rather than redocument, a medical student’s documentation of the physical exam and decision-making activity. The teaching physician is responsible for performing (or reperforming) the exam and the medical decision-making components and also needs to sign and date the student’s documentation. (Source: MLN Matters: MM10627.)
Tips for Documenting E&M Established Patient Codes
When you use E&M codes 99212-99215, you are required to document medical decision-making plus at least one of these two elements:
Per CMS guidelines, when documenting the history for an established patient E&M code, you can indicate the status of three chronic or inactive conditions, instead of documenting current elements of the history of the present illness (HPI).
E&M Versus Eye Visit Codes: Differences in Documentation
For E&M codes, documentation guidelines are standardized and recognized nationally by all payers. Furthermore, since 1997, there have been ophthalmology-specific exam element requirements for E&M codes.
For Eye visit codes, document the services listed in the CPT descriptors. These descriptors were established many years before E&M’s ophthalmology-specific exam elements, mentioned above. There are no national guidelines and no state Medicare Local Carrier Determination (LCD) policies for documenting Eye visit codes.
Never apply E&M documentation requirements to Eye visit codes or vice versa. When you are determining the level of E&M code, you can use an audit tool that takes into account a number of factors, including the level of history and the complexity of decision-making that are documented. However, you should not use that audit tool when determining which level of Eye visit code to bill.
Want an example of how the documentation requirements differ? See the chart below, which lists the documentation requirements for E&M code 99204 and Eye visit code 92004.