July 1997 Bulletin

HCFA, AMA tell how to code for E/M

Guidelines on documentation for key components

As part of its ongoing efforts to prevent fraud and abuse in the Medicare program, the Inspector General (IG) of the Department of Health and Human Services is conducting audits of teaching hospitals and private physician practices. One of the issues raised during these audits is "upcoding," especially for evaluation and management (E/M) services.

The Health Care Financing Administration (HCFA) and the American Medical Association (AMA) have developed documentation guidelines to assist physicians in selecting the appropriate level of E/M service.

E/M services include three key components: history, physical examination and medical decision-making. The complexity of these three components determines which level of E/M service may be coded.

History

There are four elements of the patient history: chief complaint, history of present illness (HPI), review of systems (ROS), and past, family, and/or social history (PFSH).

Documentation of the chief complaint should identify the reason for the encounter (e.g., symptom(s), problem(s), diagnosis, condition, patient's words, or return visit).

The HPI should indicate the location/site(s), quality (e.g., sharp, dull, throbbing), severity (minor, moderate, severe), duration, timing (with exercise, at night), context (worsening, recurrent), the modifying factors (rest, heat, limb elevation) and the associated signs and symptoms of the problem.

The ROS includes the following factors: constitutional, eyes, ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary, neurologic, psychiatric, endocrine, hematologic/lymphatic, allergic/immunologic and "all others negative."

The past medical, family and social history includes documentation of past medical history (illnesses, operations, injuries, treatments), family history (medical events, heredity, patient at risk) and social history (marital status, occupation, habits, sexual history).

The level of the history performed is calculated by the number of items documented for each element:

HISTORY TYPE	HPI	ROS	PFSH
Problem Focused	Brief 1-3 items	None	None
Expanded Problem Focused	Brief 1-3 items	Pertinent to problem 1 system	None
Detailed	Extended 4 or more items	Extended 2-9 systems	Pertinent 1 PFSH area
Comprehensive	Extended 4 or more items	Complete 10 or more systems ("all others negative")	Complete 2 or 3 PFSH areas

Physical examination

Documentation requirements for the physical examination are more problematic. Guidelines on documenting a comprehensive multisystem examination have been released by HCFA, but these are difficult for many specialists to meet. In order to allow specialists to bill for a comprehensive physical exam, HCFA and the AMA have asked the specialty societies to develop guidelines for a comprehensive single system exam. The Academy and other specialty societies have complied with this request; however, these guidelines have not yet been released by HCFA. Therefore, changes to the information given below are still possible.

HCFA has defined twelve organ systems: constitutional, eyes, ears/nose/mouth/throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, skin, neurologic, psychiatric and hematologic/lymphatic/immune.

Within the musculoskeletal organ system, there are six body areas: neck (including cervical spine and head), thoracic-lumbar spine/ribs/pelvis, and the right and left lower and upper extremities.

To document a comprehensive musculoskeletal examination, positive and relevant negative findings of the following exam elements must be noted. The number of items required is indicated in parentheses.

Constitutional:

• general appearance-development, nutrition, body habitus, deformities, attention to grooming (one example must be recorded)
• vital signs-blood pressure, supine blood pressure, pulse and regularity, respiration, temperature, height, weight (at least three items must be recorded)

Vascular Organ System:

• observation-color, capillary filling, swelling, varicosities (one example)
• palpation-pulses, temperature, edema, tenderness (one example)

Lymphatic System:

• palpation of lymph nodes in neck, axillae and/or groin (one example or "negative" statement)

Musculoskeletal System (Joints, Muscles and Bones): (each item must be recorded)

• examination of gait and station
• range of motion - range, pain, crepitation, contracture
• stability - dislocation, subluxation, laxity
• inspection/palpation - misalignment, asymmetry, crepitation, defects, tenderness, masses, effusion
• muscle strength and tone - flaccid, cog wheel, spastic (note atrophy and abnormal movements)

Neurological/Psychiatric Systems (Higher Cortical Functions, Peripheral Nerves, Coordination): (each item must be recorded)

• coordination - finger-nose, heel-shin, station, rapid alternating movements in upper and lower extremities
• deep tendon reflexes - note abnormal (e.g., Babinski's)
• sensation - touch, pain, vibration, proprioception
• mental status - mood and affect, orientation to time, place, person
• special tests if necessary - e.g., Tinel's, Babinski's, Hoffmann's, straight leg raising, Phalen's, Spurling

Skin System:

• inspection and/or palpation of skin and subcutaneous tissue - scars, rashes, lesions, café-au-lait spots, ulcers (one example)

To determine the level of examination performed, choose from the descriptions in the table below. For a comprehensive exam, all findings must be documented, both positive and relevant negative elements.

Problem Focused	Limited to affected body area or organ system (e.g., portion of body area such as a fingertip)
Expanded Problem Focused	Affected body area or organ system and other symptomatic or related organ systems (e.g., portion of body area plus other symptomatic organ system such as musculoskeletal and neurologic)
Detailed	Extended exam of affected body area(s) and other symptomatic or related organ systems (complete single body area exam)
Comprehensive	Complete single specialty exam (all elements recorded for 4 of 6 musculoskeletal body areas) or complete multispecialty exam (8 of 12 organ systems)

Medical decision-making

There are three elements of medical decision-making: number of diagnoses or management options, risk of complications and/or morbidity or mortality and the amount and complexity of the data reviewed.

Number of Diagnoses/Management Options

• identify each problem mentioned in the evaluation
• enter the number of problems in each of the categories in the second column (some have maximum values entered)
• find score for each row and add final column for total
• if encounter is dominated by counseling or coordination of care, enter 3 for total

Categories for Problems or Major New Symptoms	Number X	Points =	Score
Self-limited or minor (stable, improved, worsening	Max=2	1
Established problem (stable or improved)		1
Established problem (worsening		2
New problem, no additional workup planned	Max=1	3
New problem, additional workup planned		4
		Total Score =

Risk of Complications and/or Mortality/Morbidity

• the overall measure of risk is the highest level circled

Level of Risk	Presenting problem(s)	Diagnostic procedure(s) ordered	Management options selected
Minimal	One self-limited or minor problem (e.g., suture removal/laceration)	Laboratory tests requiring venipuncture	Rest Elastic bandages Superficial dressings
Low	Two or more self-limited or minor problems One stable chronic illness Acute uncomplicated illness or injury (e.g., simple sprain)	Superficial needle biopsies Clinical laboratory tests requiring arterial puncture Single area X-rays	OTC drugs Minor surgery with no identified risk factors Physical/occupational therapy
Moderate	One or more chronic illnesses with mild exacerbation Two or more stable chronic illnesses Acute illness with systemic symptoms Acute complicated injury	Physiologic tests under stress Multiple area X-rays Deep needle or incisional biopsy Obtain fluid from body cavity (e.g., joint, bursa, lumbar puncture) CT, MRI, bone scan	Minor surgery with identified risk factors Elective major surgery (open, percutaneous, endoscopic) Prescription drug management Closed treatment of fracture/disloca-tion without manipulation
High	One or more chronic illnesses with severe exacerbation Acute or chronic illness or injuries that pose a threat to life or bodily function (e.g., multiple trauma, pulmonary embolus) An abrupt change in neurologic status (e.g., weakness or sensory loss)	Discography Myelography Arthrogram	Elective major surgery (open, percutaneous, endoscopic) with identified risk factors Emergency major surgery (open, percutaneous, endoscopic) Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity

Amount/Complexity of Data Reviewed

Categories of Data to be Reviewed	Points
Review and/or order clinical lab tests	1
Review and/or order of tests in radiology section of CPT (includes nuclear medicine)	1
Review and/or order of tests in medicine section of CPT (e.g., EMG, SSEP, noninvasive vascular studies, pulmonary function studies, psychological testing)	1
Discussion of test results with performing physician	1
Decision to obtain old records and/or history from someone other than patient	1
Review and summarization of old records and/or obtaining history from someone other than patient, and/or discussion of case with another health care provider	2
Independent visualization of image, tracing or specimen itself (not simply review of report)	2
TOTAL

The level of medical decision making is based on the scores of the three elements, as determined below.

Decision Making Type	Number Diagnoses/ Management Options	Risk of Complications and/or Morbidity/Mortality	Amount/Com-plexity of Data Reviewed
Straightforward	Minimal 1	Minimal	Minimal or low 1
Low Complexity	Limited 2	Low	Limited 2
Moderate Complexity	Multiple 3	Moderate	Moderate 3
High Complexity	Extensive 4	High	Extensive 4

To select the appropriate level of E/M service, use the findings from the history, examination and decision-making sections above. Choose the appropriate code based on the column with the most circled items or average the items to make your decision.
The typical time is listed with each code as an example only.

Established Office Patient Codes

History	Not applicable	Problem focused	Expanded problem focused	Detailed	Comprehensive
Examination	Not applicable	Problem focused	Expanded problem focused	Detailed	Comprehensive
Decision Making	Not applicable	Straightforward	Low Complexity	Moderate Complexity	High Complexity
Code	99211 (5 min)	99212 (10 min)	99213 (15 min)	99214 (25 min)	99215 (40 min)

New Office Patient Codes

History	Problem focused	Expanded problem focused	Detailed	Comprehensive	Comprehensive
Examination	Problem focused	Expanded problem focused	Detailed	Comprehensive	Comprehensive
Decision Making	Straightforward	Straightforward	Low Complexity	Moderate Complexity	High Complexity
Code	99201 (10 min)	99202 (20 min)	99203 (30 min)	99204 (45 min)	99205 (60 min)