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Throughout the country, physicians have been taught to make sure that they capture all of the elements of history of present illness (HPI), review of systems (ROS), past family and social history (PFSH), and physical exam (PE). However, either they have not been taught or have failed to show that the driver of evaluation and management codes (E&M) is MDM. Let me try to provide an example.

Say a patient was seen in the emergency room (ED) for left flank pain down to the groin associated with nausea, and the final E&M code assignment was CPT® code 99285, problem(s) indicative of high severity with an immediate, significant threat to life or physiologic function. The patient was assessed in triage, and documentation showed that the patient did not appear to be in any apparent distress. The triage nurse assessed the patient as emergency severity index (ESI) 3 (urgent) and documented that the patient was comfortable, without any clinical suspicions of infection. The patient’s temperature was 97.6 and pain assessment was measured as 5/10. Although the provider did dot all “i’s” and cross all “t’s,” with the history being comprehensive and the exam detailed, the medical decision-making was based on the presenting signs and symptoms; tests were then ordered and risk was the driver of the final code for this ED visit. 

Now I don’t pretend to like the entire methodology of E&M, and until the Centers for Medicare & Medicaid Services (CMS) decides to do away with the entire thing (there have been prior attempts to get to a single E&M level, much like the clinic level G code), we are stuck with the current method of episode coding and chart auditing, which is based on CMS guidelines and the audit sheet known as the Marshfield Tool. For those of you who don’t know, the Marshfield tool was designed in the early 1990s by the Marshfield Clinic (offices located throughout Wisconsin), in conjunction with their regional Medicare carrier, while beta-testing Medicare’s 1995 Evaluation and Management Documentation Guidelines. Although the Marshfield audit sheet never made it to the Official Documentation Guidelines, this tool is still used today to audit E&M level assignment and evaluate the complexity of MDM. The tool was designed so that all three areas (history, PE, and MDM) would be measured equally. However, from an auditing standpoint, the medical decision-making component has evolved to represent a litmus test of the other two key elements. What does this mean? It means that it may not be necessary to do a full history or a full PE if there is no clinical indication that warrants the consideration of the elements in each area.

So, with the patient above, it turns out that the patient had a history of kidney stones, and now the provider, as part of the differential diagnosis (non-renal causes of flank pain, such as musculoskeletal problems, parenchymal problems, which involve the actual kidney tissue, and non-parenchymal problems, which often relate to impaired kidney drainage), needs to include recurrence of kidney stones due to prior history. The provider ordered lab tests, which included a urinalysis and straining of urine, along with a CT scan without contrast.

However, simply noting that a lab test was ordered is insufficient documentation to support the ordering of the lab test. The provider also ordered Toradol and Zofran via intravenous push (IVP). However, the documentation did not include that the Toradol was ordered for pain and that the Zofran was ordered to treat the patient’s nausea. 

Since in the differential diagnosis, the physician is considering including renal stones (nephrolithiasis) and flank pain radiating to the groin in the absence of fever, pathognomonic of kidney stones, the documentation in the chart must note the provider’s train of thought. The auditor, who is not involved in the direct care of the patient, should not be expected to interpret that any clinical testing ordered is to assess a particular condition. Nor is the auditor expected to know that any medication ordered is intended to treat a particular diagnosis, unless documented as such. 

The provider needs to note explicitly as to the intention of the test and medication in the chart documentation. Therefore, it would also be necessary for the provider to note that the intention of the urine straining is to look for “sludge” (the buildup of tiny crystallized minerals in the kidney, which blocks the flow of urine) that could lead to a conclusive diagnosis. The provider can’t write “CT scan” and expect a reviewer to know what she or he was thinking. 

If clinical documentation warranting the test being done is present, and if the CT is noted as “unremarkable,” that is accepted documentation based on the fact that a renal calculus and other non-calculus diagnosis that may have been contemplated and documented in the medical record were ruled out. An ordered test and the documentation not only support medical necessity, but it helps an auditor determine the level of medical decision-making in reference to the provider’s line of thinking in the differential diagnosis considered. If the provider needs to review the patient’s prior records, again, checking off a box is insufficient documentation in justifying the request. The guidelines ask that the provider document the reason to review any additional information, and if the additional information has been obtained, what results were derived from the information.

Why is this necessary? Because any information obtained implies an increase in the complexity and volume of the data. If additional information is obtained from the family, simply stating “additional history obtained from family” is notenough for documentation verification. The provider needs to cite relevant findings or document explicitly that there were no findings. 

Dr. Emily Hirsh, in her June 5, 2012 article titled “Let’s Play a Game: Emergency Medical Documentation Coding for Emergency Physicians (not coders)” said it best about sufficient documentation for medical decision-making:

  • Diagnoses and/or management options (DMO): If someone is being admitted for further workup, state it in your chart.
  • DMO: If someone is being discharged with further workup planned, state that in your chart.
  • Data: If you visualize a study yourself, state it in your chart (“electrocardiogram (ECG) which I ordered and visualized myself shows (x); Chest X-ray (CXR) which I ordered and visualized myself shows (y)”).
  • Data: If you obtained history from someone else or reviewed an old chart, state it in your note. (“Review of the old chart shows….” or “I spoke with the patient’s daughter, who provided further history of….”)
  • Risk: If you give IV/IM narcotics, state it in your chart (“IV morphine given for pain”); this demonstrates a high level of risk.
  • Risk: If someone is at high risk based on his/her presentation (as seen on the risk table), state it. (“Patient was at high level of risk because this was a motor vehicle crash (MVC) that could pose threat to life” or “patient had acute change in neurologic status” or “patient has a psychiatric illness and is at risk to himself”, etc.)”

To read the article in its entirety, go online to http://www.drhem.com/education/wp-content/uploads/2015/04/Lets-Play-a-Game-Emergency-Medical-Documentation-Emily-Hirsh-MD.pdf.

Again, in our patient example above, the final diagnosis was renal colic; the patient’s pain assessment prior to discharge was assessed at 2/10 and additional outpatient follow-up was not documented in the medical record that was reviewed. The combined final result for MDM was high complexity, and therefore the final E&M arrived at during the audit was 99284 (problems are high severity and require urgent evaluation by the physician, but do not pose an immediate significant threat to life or physiologic function). So before assigning CPT code 99285, simply ask yourself, was the problem(s) indicative of high severity and did it pose an immediate significant threat to life or physiologic function? 

In conclusion, per CMS Manual System Pub. 100-04, Medicare Claims Processing Transmittal 178, “medical necessity of a service is the overarching criterion for payment, in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during (the provision of treatment), or as soon as practicable after it is provided, in order to maintain an accurate medical record.” This message of medical necessity is also reiterated in the Social Security Act:

All services under Medicare must be reasonable and necessary as defined in Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section states, “…no payment may be made for any expenses incurred for items or services, which are not reasonable and necessary for the diagnosis or treatment of injury or to improve the functioning of a malformed body member.” Therefore, medical necessity is the first consideration in reviewing all services.

Although the above pertains to CMS, non-Medicare payers who audit E&M services do not necessarily follow contractor-specific guidelines, but rather general CMS guidelines.


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