DETERMINING THE OVERALL LEVEL OF MEDICAL DECISION MAKING

The overall level of decision making is decided by placing the level of each of the three components into the appropriate box in a manner that allows them to be summed up to rate the overall decision making as straightforward, low complexity, moderate complexity, or high complexity.

DOCUMENTATION

The use of templates, either preprinted forms or embedded in an electronic patient record (see Appendix H), is an efficient means of addressing the documentation of decision making. Rather than counting or scoring the elements of the three components and actually filling out a grid like the one in the Table , a template can be constructed in collaboration with the compliance officer of your practice or institution to include prompts that capture the required data necessary to document complexity. Solo practitioners may require the assistance of their specialty association or a consultant to develop appropriate templates

Remember: Clinically, there is a close relationship between the nature of the presenting problem and the complexity of medical decision making. For example:

• Patient A comes in for a prescription refill—straightforward decision making 

• Patient B presents with suicidal ideation—decision making of high complexity

Select the Appropriate Level of E/M Service

As noted earlier, each category of E/M service has three to five levels of work associated with it. Each level of work has a descriptor of the service and the required extent of the three key components of work. For example

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Descriptor: Initial hospital care, per day for the evaluation and management of a patient, which requires these three key components:

• A comprehensive history 

• A comprehensive examination 

• Medical decision making that is of high complexity

For new patients, the three key components (history, examination, and medical decision making) must meet or exceed the stated requirements to qualify for each level of service for office visits, initial hospital care, office consultations, initial inpatient consultations, confirmatory consultations, emergency department services, comprehensive nursing facility assessments, domiciliary care, and home services.

CONTENT AND DOCUMENTATION REQUIREMENTS

System/Body Area :  Constitutional

Elements of Examination :  

• Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff) 
• General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming) 

System/Body Area :  Eyes

Elements of Examination :  

• Inspection of conjunctivae and lids 
• Examination of pupils and irises (eg, reaction to light and accommodation, size and symmetry) 
• Ophthalmoscopic examination of optic discs (eg, size, C/D ratio, appearance) and posterior segments (eg, vessel changes, exudates, hemorrhages)

System/Body Area :Ears, Nose, Mouth and Throat 

Elements of Examination :  

• External inspection of ears and nose (eg, overall appearance, scars, lesions, masses) 
• Otoscopic examination of external auditory canals and tympanic membranes 
• Assessment of hearing (eg, whispered voice, finger rub, tuning fork) 
• Inspection of nasal mucosa, septum and turbinates 
• Inspection of lips, teeth and gums 
• Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx 

System/Body Area :Neck

Elements of Examination :  

• Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus) Examination of thyroid (eg, enlargement, tenderness, mass) 

GENERAL MULTI-SYSTEM EXAMINATIONS

To qualify for a given level of multi-system examination, the following content and documentation requirements should be met:

Problem Focused Examination – should include performance and documentation of one to five elements identified by a bullet (•) in one or more organ system(s) or body area(s). 

Expanded Problem Focused Examination – should include performance and documentation of at least six elements identified by a bullet (•) in one or more organ system(s) or body area(s). 

Detailed Examination – should include at least six organ systems or body areas. For each system/area selected, performance and documentation of at least two elements identified by a bullet (•) is expected. Alternatively, a detailed examination may include performance and documentation of at least twelve elements identified by a bullet (•) in two or more organ systems or body areas. 

Comprehensive Examination – should include at least nine organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet (•) should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least two elements identified by a bullet is expected. 

SINGLE ORGAN SYSTEM EXAMINATIONS

 To qualify for a given level of single organ system examination, the following content and documentation requirements should be met:

Problem Focused Examination – should include performance and documentation of one to five elements identified by a bullet (•), whether in a box with a shaded or unshaded border. 

Expanded Problem Focused Examination – should include performance and documentation of at least six elements identified by a bullet (•), whether in a box with a shaded or unshaded border. 

Detailed Examination – examinations other than the eye and psychiatric examinations should include performance and documentation of at least twelve elements identified by a bullet (•), whether in a box with a shaded or unshaded border. 

• Eye and psychiatric examinations should include the performance and documentation of at least nine elements identified by a bullet (•), whether in a box with a shaded or unshaded border. 

Comprehensive Examination – should include performance of all elements identified by a bullet (•), whether in a shaded or unshaded box. Documentation of every element in each box with a shaded border and at least one element in a box with an unshaded border is expected. 

DOCUMENTATION OF E/M SERVICES

This publication provides definitions and documentation guidelines for the three key components of E/M services and for visits which consist predominately of counseling or coordination of care. The three key components--history, examination, and medical decision making--appear in the descriptors for office and other outpatient services, hospital observation services, hospital inpatient services, consultations, emergency department services, nursing facility services, domiciliary care services, and home services. While some of the text of CPT has been repeated in this publication, the reader should refer to CPT for the complete descriptors for E/M services and instructions for selecting a level of service. Documentation guidelines are identified by the symbol • DG.

The descriptors for the levels of E/M services recognize seven components which are used in defining the levels of E/M services. These components are: 

• history; 
• examination; 
• medical decision making; 
• counseling; 
• coordination of care; 
• nature of presenting problem; and 
• time.  

The first three of these components (i.e., history, examination and medical decision making) are the key components in selecting the level of E/M services. In the case of visits which consist predominantly of counseling or coordination of care, time is the key or controlling factor to qualify for a particular level of E/M service.

Because the level of E/M service is dependent on two or three key components, performance and documentation of one component (eg, examination) at the highest level does not necessarily mean that the encounter in its entirety qualifies for the highest level of E/M service. 

These Documentation Guidelines for E/M services reflect the needs of the typical adult population. For certain groups of patients, the recorded information may vary slightly from that described here. Specifically, the medical records of infants, children, adolescents and pregnant women may have additional or modified information recorded in each history and examination area. 

As an example, newborn records may include under history of the present illness (HPI) the details of mother's pregnancy and the infant's status at birth; social history will focus on family structure; family history will focus on congenital anomalies and hereditary disorders in the family. In addition, the content of a pediatric examination will vary with the age and development of the child. Although not specifically defined in these documentation guidelines, these patient group variations on history and examination are appropriate.  

GENERAL PRINCIPLES OF MEDICAL RECORD DOCUMENTATION

The principles of documentation listed below are applicable to all types of medical and surgical services in all settings. For Evaluation and Management (E/M) services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient’s status. The general principles listed below may be modified to account for these variable circumstances in providing E/M services.

1. The medical record should be complete and legible. 

2. The documentation of each patient encounter should include: 

• reason for encounter and relevant history, physical examination findings, and prior diagnostic test results; 
• assessment, clinical impression, or diagnosis; 
• plan for care; and 
• date and legible identity of the observer. 

3. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred. 

4. Past and present diagnoses should be accessible to the treating and/or consulting physician. 

5. Appropriate health risk factors should be identified. 

6. The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented. 

7. The CPT and ICD-9-CM codes reported on the health insurance claim form should be supported by the documentation in the medical record. 

WHAT IS DOCUMENTATION

 WHY IS IT IMPORTANT?

Medical record documentation is required to record pertinent facts, findings, and observations about an individual’s health history including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high quality care. The medical record facilitates:

• the ability of the physician and other healthcare professionals to evaluate and plan the patient’s immediate treatment, and to monitor his/her healthcare over time. 
• communication and continuity of care among physicians and other healthcare professionals involved in the patient’s care; 
• accurate and timely claims review and payment; 
• appropriate utilization review and quality of care evaluations; and 
• collection of data that may be useful for research and education.  

An appropriately documented medical record can reduce many of the hassles associated with claims processing and may serve as a legal document to verify the care provided, if necessary.

WHAT DO PAYERS WANT AND WHY?  

Because payers have a contractual obligation to enrollees, they may require reasonable documentation that services are consistent with the insurance coverage provided. They may request information to validate:

• the site of service; 
• the medical necessity and appropriateness of the diagnostic and/or therapeutic services provided; and/or 
• that services provided have been accurately reported.