Coding Corner: The top three E/M documentation problems

February 01, 2018
Area(s) of Interest: Emergency Services Payor Issues and Reimbursement Practice Management 

CPR’s “Coding Corner” focuses on coding, compliance, and documentation issues relating specifically to physician billing. This month’s tip comes from Brenda Edwards, contributing member of AAPC, a training and credentialing association for the business side of health care.

Proper documentation of evaluation and management (E/M) services is key to appropriate reimbursement. Three common areas where E/M documentation may fall short are within the history of present illness (HPI), the review of systems (ROS), and the assessment and plan (A/P). 

HPI should explicitly describe the chief complaint
When documenting HPI, you must provide specific details to identify the presenting problem, along with its severity, location and duration. Consider the following example:

The patient presents today for follow-up. Patient seems to be improving and has no new complaints. We’ll plan to see him back in three months.

This documentation lacks the specific details to support medical necessity for this visit—although those details undoubtedly were discussed during the visit. Here’s how the note might look when these details are documented:

The patient presents today for follow-up on type 2 diabetes. He has had type 2 diabetes for approx. the past 14 years, which was getting out of control. The patient now keeps a diet and exercise log, in addition to the changes in Lantis we made at the last visit. There is an improvement in his blood sugars that he has been recording at home.

Simply adding of a few pieces of information provides a complete HPI, including duration (14 years), severity (type 2 diabetes), modifying factor (Lantis) and quality (improvement in blood sugars).

Another concept you could use to capture a relevant HPI is:

  • “who”: patient identifier
  • “what”: chief complaint
  • “when”: duration of complaint
  • “where”: specific location of the presenting problem
  • “why”: modifying factors, timing or context
  • “how”: quality, severity or signs/symptoms.

This method will ensure a complete HPI for each encounter.

Find a happy medium when documenting ROS
The ROS can be a form the patient completes, or a verbal conversation that occurs with the provider asking the patient if there are systemic complaints. A comprehensive ROS is not necessary at every visit; conversely, statements such as “ROS negative,” “ROS as above” or “ROS non-contributory” typically are insufficient.

Here’s an example of a less-than-ideal ROS:

HPI: The patient has complained of a cough for the past three days. They have tried to use over-the-counter sinus medication without relief. There are no other complaints at this time.

ROS: As per HPI

HPI includes the duration (three days) and modifying factor (over-the-counter sinus medication), but there is not enough additional information to support the ROS. Possible solutions might include:

  • Documentation of a reviewed history intake form that the patient completed or updated; or
  • A more in-depth HPI with additional information to support some of the ROS elements.

Excessive documentation of the ROS can also be a problem. Document a comprehensive ROS only when clinically relevant.

A/P should include only current issues
A/P documentation must include more than a list of diagnosis codes without explanation of severity, medication management and other details. The A/P should explain what was found; what labs, X-rays, or other services might be ordered or performed; and the expected outcome by the next encounter. For example, an accurate A/P might look like this:

Assessment and Plan
1. Type 1 Diabetes; no changes in medication at this time. Will check A1C in three months prior to next visit.
2. Hypertension – stable on Triamterene 37.5 mg with no changes in dosage.
3. Migraines – followed by Dr. Smith and current medications are not affecting hypertension.

An accurate and complete A/P would include all conditions addressed at that encounter, or may include conditions that could affect the treatment of conditions currently addressed. For example, condition 3, above, is elaborated upon to indicate another provider is following it, and the medication does not have an effect on chronic conditions being treated at this encounter. The A/P should not include historical information that is not relevant to the present encounter.

Regarding diagnosis code order, the American Academy of Family Physicians offers the following advice:

Q: Does the order in which diagnoses are listed on the claim matter? Must the order on the encounter form (documentation) match the order on the claim?

A: Yes, the order does matter. The physician should list on the encounter form the diagnosis (ICD-9) code that is associated with the main reason for the visit. This is the primary diagnosis, and in most cases it should be listed first on the claim form, followed by codes that describe any coexisting conditions that affect patient care, treatment or management. Each diagnosis code should be linked to the service (CPT) code to which it relates; this helps to establish medical necessity. Any changes to codes or to the order in which they are listed on the claim should be approved by the physician. In some cases, the ICD-9 guidelines may require that certain codes be reordered. For example, the physician may list an ulcer of the ankle first, followed by a related condition such as diabetes. However, because ICD-9 instructs to “Code, if applicable, any causal condition first,” the code for diabetes with other specified manifestations, 250.8X, might need to be listed first, followed by 707.13 for the ulcer.

Although this refers to ICD-9, the same rules hold true for ICD-10. The reason for the visit should be the primary diagnosis, followed by codes for any coexisting conditions affecting the care of the patient. 


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