MAR 18, 2016
6 Questions Answered on E/M Coding
In determining the level of service for an E/M visit code, you need to review three areas of the exam: history, exam and medical decision-making. Practices often are concerned that they are not accurately capturing the data needed for the level of service. Below are answers to six common E/M coding questions submitted to the Academy.
Q1. Our office has paper charts. We have new patients fill out a medical-history questionnaire that includes review of systems and past, family, social histories. Does the physician need to sign this form or is it appropriate for the technician to sign it?
A. Since this is part of the history component of the exam, the physician must sign and date the form as it pertains to the examination. If the patient marked a positive ROS, the physician can confirm or indicate treatment as documented.
Q2. When is it appropriate to indicate “all others negative” for the review of systems?
A. It’s appropriate to state all others negative when documenting the clinical relevant systems and reviewing others confirming that there is no positive finding. You usually document this for new patients, since a complete review of systems is necessary. Established patients do not need a complete review of systems; instead you should focus on the reason the patient presented. If you perform a complete review of systems when it is not necessary, it can lead to over inflation of the service level. When using an electronic health record system, be careful that it does not copy-forward or copy-paste this information onto a new exam. Auditors often request previous records to confirm that these elements of the history were not brought forward.
Q3. When should I count certain documentation, such as allergies. Should I put allergies in past medical history, or under allergic/immunologic review of systems?
A. You can only count the element of allergies or any other condition once. You can decide as to where it should belong, based on the reason the patient presented.
Q4. How should we document prescription drug management for the table of risk? How does this affect the level of exam?
A. Whether using E/M codes or eye-visit codes, the physician must document that s/he has evaluated appropriate medications based on the patient’s condition. You can do so by stating that a prescription is started, discontinued, or that the current medication is effective and can be continued. It’s not adequate for this component of the medical decision-making to simply document what medications the patient is currently taking.
Q5. How should we update the chart to note when there have been no changes to the review of systems and/or past, family social history since the last exam? Is there a way to avoid having to re-document the same findings?
A. You can state that there have been no changes to ROS and/or PFSH since last exam XX/XX/XX. You must reference the date of the exam. If this exam is audited, make sure to include the date of service indicated and the ROS and PFSH. That way the auditor will know actually which systems and which past, family and social histories you obtained and documented that day.
Q6. The audit tool for E/M services states “review of old records and/or additional history from other than the patient.” If I summarize my previous records of this patient, can this count toward medical decision-making?
A. Review of records does not count toward medical decision-making if it is your own documentation. Only records from another source, such as a referring physician, would count as part of medical decision-making.