DOCUMENTATION OF THE COMPLEXITY OF MEDICAL DECISION MAKING

The levels of E/M services recognize four types of medical decision making (straightforward, low complexity, moderate complexity and high complexity). Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by: 

• the number of possible diagnoses and/or the number of management options that must be considered;
•  the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed; and 
• the risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options.

NUMBER OF DIAGNOSES OR MANAGEMENT OPTIONS 

The number of possible diagnoses and/or the number of management options that must be considered is based on the number and types of problems addressed during the encounter, the complexity of establishing a diagnosis and the management decisions that are made by the physician.

Generally, decision making with respect to a diagnosed problem is easier than that for an identified but undiagnosed problem. The number and type of diagnostic tests employed may be an indicator of the number of possible diagnoses. Problems which are improving or resolving are less complex than those which are worsening or failing to change as expected. The need to seek advice from others is another indicator of complexity of diagnostic or management problems. 

DG: For each encounter, an assessment, clinical impression, or diagnosis should be documented. It may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation.

For a presenting problem with an established diagnosis the record should reflect whether the problem is: a) improved, well controlled, resolving or resolved; or, b) inadequately controlled, worsening, or failing to change as expected.  

AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWED 

The amount and complexity of data to be reviewed is based on the types of diagnostic testing ordered or reviewed. A decision to obtain and review old medical records and/or obtain history from sources other than the patient increases the amount and complexity of data to be reviewed. 

Discussion of contradictory or unexpected test results with the physician who performed or interpreted the test is an indication of the complexity of data being reviewed. On occasion the physician who ordered a test may personally review the image, tracing or specimen to supplement information from the physician who prepared the test report or interpretation; this is another indication of the complexity of data being reviewed. 

DG: If a diagnostic service (test or procedure) is ordered, planned, scheduled, or performed at the time of the E/M encounter, the type of service, eg, lab or x-ray, should be documented. 

DG: The review of lab, radiology and/or other diagnostic tests should be documented. A simple notation such as "WBC elevated" or "chest x-ray unremarkable" is acceptable. Alternatively, the review may be documented by initialing and dating the report containing the test results. 

DG: A decision to obtain old records or decision to obtain additional history from the family, caretaker or other source to supplement that obtained from the patient should be documented. 

DG: Relevant findings from the review of old records, and/or the receipt of additional history from the family, caretaker or other source to supplement that obtained from the patient should be documented. If there is no relevant information beyond that already obtained, that fact should be documented. A notation of “Old records reviewed” or “additional history obtained from family” without elaboration is insufficient. 

DG: The results of discussion of laboratory, radiology or other diagnostic tests with the physician who performed or interpreted the study should be documented. 

DG: The direct visualization and independent interpretation of an image, tracing or specimen previously or subsequently interpreted by another physician should be documented. 

Eye Examination

Elements of Examination :

• Test visual acuity (Does not include determination of refractive error) 
• Gross visual field testing by confrontation 
• Test ocular motility including primary gaze alignment 
• Inspection of bulbar and palpebral conjunctivae 
• Examination of ocular adnexae including lids (eg, ptosis or lagophthalmos), lacrimal glands, lacrimal drainage, orbits and preauricular lymph nodes 
• Examination of pupils and irises including shape, direct and consensual reaction (afferent pupil), size (eg, anisocoria) and morphology 
• Slit lamp examination of the corneas including epithelium, stroma, endothelium, and tear film 
• Slit lamp examination of the anterior chambers including depth, cells, and flare Slit lamp examination of the lenses including clarity, anterior and posterior capsule, cortex, and nucleus
•  Measurement of intraocular pressures (except in children and patients with trauma or infectious disease) 

Ophthalmoscopic examination through dilated pupils (unless contraindicated) of Optic discs including size, C/D ratio, appearance (eg, atrophy, cupping, tumor elevation) and nerve fiber layer Posterior segments including retina and vessels (eg, exudates and hemorrhages)

Genitourinary Examination 

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:Neck

Elements of Examination :  

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

System/Body Area:Respiratory

Elements of Examination : 

Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement) 

Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs) 

System/Body Area:Cardiovascular

Elements of Examination : 

Auscultation of heart with notation of abnormal sounds and murmurs 

Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (e.g. pulses, temperature, edema, tenderness) 

System/Body Area:Chest (Breasts)

System/Body Area:Gastrointestinal (Abdomen)

 

Elements of Examination : 

Examination of abdomen with notation of presence of masses or tenderness 

Examination for presence or absence of hernia 

Examination of liver and spleen 

Obtain stool sample for occult blood when indicated 

System/Body Area:Genitourinary

 

Elements of Examination : 

MALE: Inspection of anus and perineum 

• Examination (with or without specimen collection for smears and cultures) of genitalia including: 
• Scrotum (eg, lesions, cysts, rashes) Epididymides (eg, size, symmetry, masses) 
• Testes (eg, size, symmetry, masses)
• Urethral meatus (eg, size, location, lesions, discharge) 
• Penis (eg, lesions, presence or absence of foreskin, foreskin retractability, plaque, masses, scarring, deformities) 

Digital rectal examination including: 

• Prostate gland (eg, size, symmetry, nodularity, tenderness)
• Seminal vesicles (eg, symmetry, tenderness, masses, enlargement) 
• Sphincter tone, presence of hemorrhoids, rectal masses 

System/Body Area:Genitourinary

 

Elements of Examination : 

FEMALE:

Includes at least seven of the following eleven elements identified by bullets:

•  Inspection and palpation of breasts (eg, masses or lumps, tenderness, symmetry, nipple discharge) 
•  Digital rectal examination including sphincter tone, presence of hemorrhoids, rectal masses  

Pelvic examination (with or without specimen collection for smears and cultures) including: 

• External genitalia (eg, general appearance, hair distribution, lesions) 
• Urethral meatus (eg, size, location, lesions, prolapse) 
• Urethra (eg, masses, tenderness, scarring) 
• Bladder (eg, fullness, masses, tenderness) 
• Vagina (eg, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele) 
• Cervix (eg, general appearance, lesions, discharge) 
• Uterus (eg, size, contour, position, mobility, tenderness, consistency, descent or support) Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity) 
• Anus and perineum

Ear, Nose and Throat Examination

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)
•  Assessment of ability to communicate (eg, use of sign language or other communication aids) and quality of voice 

System/Body Area :  Head and Face

Elements of Examination : 

• Inspection of head and face (eg, overall appearance, scars, lesions and masses) 
• Palpation and/or percussion of face with notation of presence or absence of sinus tenderness Examination of salivary glands 
• Assessment of facial strength 

System/Body Area :  Eyes

Elements of Examination : Test ocular motility including primary gaze alignment 

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

 

Elements of Examination : 

• Otoscopic examination of external auditory canals and tympanic membranes including pneumo-otoscopy with notation of mobility of membranes 
• Assessment of hearing with tuning forks and clinical speech reception thresholds (eg, whispered voice, finger rub) 
• External inspection of ears and nose (eg, overall appearance, scars, lesions and masses) 
• Inspection of nasal mucosa, septum and turbinates 
• Inspection of lips, teeth and gums 
• Examination of oropharynx: oral mucosa, hard and soft palates, tongue, tonsils and posterior pharynx (eg, asymmetry, lesions, hydration of mucosal surfaces) 
• Inspection of pharyngeal walls and pyriform sinuses (eg, pooling of saliva, asymmetry, lesions) Examination by mirror of larynx including the condition of the epiglottis, false vocal cords, true vocal cords and mobility of larynx (Use of mirror not required in children) 
• Examination by mirror of nasopharynx including appearance of the mucosa, adenoids, posterior choanae and eustachian tubes (Use of mirror not required in children) 

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) 

Evaluation and Management Services

System/Body Area :Cardiovascular 

Elements of Examination :

• Palpation of heart (eg, location, size, thrills) 
• Auscultation of heart with notation of abnormal sounds and murmurs 

Examination of: 

• carotid arteries (eg, pulse amplitude, bruits) 
• abdominal aorta (eg, size, bruits) 
• femoral arteries (eg, pulse amplitude, bruits) 
• pedal pulses (eg, pulse amplitude) 
• extremities for edema and/or varicosities 

System/Body Area :Chest (Breasts)

Elements of Examination :

• Inspection of breasts (eg, symmetry, nipple discharge) 
• Palpation of breasts and axillae (eg, masses or lumps, tenderness) 

System/Body Area :Gastrointestinal (Abdomen)

Elements of Examination :

• Examination of abdomen with notation of presence of masses or tenderness 
• Examination of liver and spleen 
• Examination for presence or absence of hernia 
• Examination (when indicated) of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses 
• Obtain stool sample for occult blood test when indicated 

System/Body Area :Genitourinary 

Elements of Examination :

MALE: 

• Examination of the scrotal contents (eg, hydrocele, spermatocele, tenderness of cord, testicular mass)
•  Examination of the penis 
• Digital rectal examination of prostate gland (eg, size, symmetry, nodularity, tenderness) 

FEMALE: 

Pelvic examination (with or without specimen collection for smears and cultures), including 

• Examination of external genitalia (eg, general appearance, hair distribution, lesions) and vagina (eg, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele) 
• Examination of urethra (eg, masses, tenderness, scarring) 
• Examination of bladder (eg, fullness, masses, tenderness) Cervix (eg, general appearance, lesions, discharge) 
• Uterus (eg, size, contour, position, mobility, tenderness, consistency, descent or support) Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity) 

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.