The importance of E/M documentation guidelines
Most new patients who enter your office are in pain and want to get a chiropractic adjustment as soon as possible. If you skip the evaluation and management (E/M) process, you could miss important clinical information and cause complications to arise. Make sure to document a thorough history and examination of the patient prior to any type of treatment. This article provides information on the (E/M) documentation guidelines.
The E/M office visit codes and guidelines were significantly updated and made available on Jan. 1, 2021. These guidelines relate to new–patient CPT codes 99202, 99203, 99204, 99205 and established–patient CPT codes 99212, 99213, 99214 and 99215. In 2019, the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS) put together an initiative called “Patients over Paperwork” to reduce administrative burden and improve the health care system. To determine if a patient is a candidate for chiropractic care, DCs should start by conducting a thorough examination, documenting the patient’s history and considering potential clinical treatment options.
Choosing the correct E/M code is determined using either total time on the day of the encounter or medical decision–making (MDM). History and/or physical examinations have been eliminated as components for code selection. Although a provider’s work in capturing the patient’s pertinent history and performing a relevant physical examination contributes to both time and MDM, these elements alone do not determine the appropriate code level. The history and/or examination should continue to be documented for the visit. The 2021 E/M code descriptors have been revised to state that health care professionals should perform a “medically appropriate history and/or examination.”
Total time includes both face-to-face and non-face-to-face services. Time must be documented in the health record when it is used as the basis for code selection. The primary goal of documenting time is to ensure an accurate record of the actual total time spent on patient care on the date of the encounter. Insurance companies may have additional criteria regarding the acceptable level of documentation detail and should be contacted for their specifications, including delineations of both face-to-face and non-face-to-face time. Time may be used to select a code level in office or other outpatient services whether or not counseling and/or coordination of care dominates the service. Time may only be used for selecting the level of the other E/M services when counseling and/or coordination of care dominates the service.
Time includes the following activities when performed:
- Preparing to see the patient (e.g., review of tests)
- Obtaining and/or reviewing separately obtained history
- Performing a medically appropriate examination and/or evaluation
- Counseling and educating the patient/family/caregiver
- Ordering medications, tests or procedures
- Referring and communicating with other health care professionals (when not separately reported)
- Documenting clinical information in the electronic or other health record
- Independently interpreting results (not separately reported) and communicating results to the patient/ family/caregiver
- Care coordination (not separately reported)
Do not count time spent on the following:
- The performance of other services reported separately
- Teaching that is general and not limited to discussion that is required for the management of a specific patient
The changes will remove the burden of tallying up key components and instead allow providers to choose E/M levels based on either decision-making or time. The time ranges are as follows:
- 99201: Deleted
- 99202: Must meet or exceed 15 minutes
- 99203: Must meet or exceed 30 minutes
- 99204: Must meet or exceed 45 minutes
- 99205: Must meet or exceed 60 minutes
- 99212: Must meet or exceed 10 minutes
- 99213: Must meet or exceed 20 minutes
- 99214: Must meet or exceed 30 minutes
- 99215: Must meet or exceed 40 minutes
MDM includes establishing diagnoses, assessing the status of a condition and/or selecting a management option. MDM in the office or other outpatient services codes is defined by three elements:
- The number and complexity of problem(s) addressed during the encounter.
- The amount and/or complexity of data to be reviewed and analyzed. These data include medical records, tests and/or other information obtained, ordered, reviewed and analyzed for the encounter. This includes information obtained from multiple sources or inter-professional communications not reported separately and interpretation of tests not reported separately. Ordering a test is included in the category of test result(s) and the review of the test result is part of the encounter and not a subsequent encounter. Ordering a test may include those considered, but not selected after shared decision-making. For example, a patient may request diagnostic imaging that is not necessary for their condition and discussion of the lack of benefit may be required. Alternatively, a test may normally be performed, but due to the risk for a specific patient, it is not ordered.
- The risk of complications and/or morbidity or mortality of patient management decisions made at the visit, associated with the patient’s problem(s), the diagnostic procedure(s), treatment(s). This includes the possible management options selected and those considered but not selected, after shared MDM with the patient and/or family. For example, a decision about hospitalization includes consideration of alternative levels of care.
Four types of MDM are recognized: 1. straightforward, 2. low, 3. moderate and 4. high. The concept of the level of MDM does not apply to 99211. Shared MDM involves patient and/or family preferences, patient and/or family education and explaining risks and benefits of management options.
In the new MDM definitions, “independent historian” is defined in the CPT code set as an individual (e.g., parent, guardian, surrogate, spouse, witness) who provides a history in addition to a history provided by the patient who is unable to provide a complete or reliable history (e.g., due to developmental stage, dementia or psychosis) or because a confirmatory history is judged to be necessary.
In the case where there may be conflict or poor communication between multiple historians and more than one historian is needed, the independent historian requirement is met. The key to this definition is that the independent historian should provide additional information and not merely restate information that may have already been provided by the patient.
One element used in selecting the appropriate E/M code is the number and complexity of the problems at an encounter. Multiple new or established conditions may be addressed at the same time and may affect MDM. Symptoms may cluster around a specific diagnosis and each symptom is not necessarily a unique condition. Comorbidities/underlying diseases, in and of themselves, are not considered in selecting a level of E/M services unless they are addressed, and their presence increases the amount and/or complexity of data to be reviewed and analyzed or the risk of complications and/or morbidity or mortality of patient management. The final diagnosis for a condition does not, in and of itself, determine the complexity or risk, as extensive evaluation may be required to reach the conclusion that the signs or symptoms do not represent a highly morbid condition. The term “risk” as used in these definitions relates to risk from the condition. While condition risk and management risk may often correlate, the risk from the condition is distinct from the risk of the management.
MARTY KOTLAR, DC, CPCO, CBCS, is the president of Target Coding. Over the last 12 years, he has helped hundreds of chiropractors, physical therapists and acupuncturists with compliance as it relates to billing, coding, documentation, Medicare and HIPAA. Kotlar is certified in compliance, a certified coding specialist, a contributing author to many coding and compliance journals and a guest speaker at many state association conventions. He can be reached at 800-270-7044, firstname.lastname@example.org and TargetCoding.com.