Key Components in an E/M Healthcare Audit

Let's talk about just some of the key components and some of the issues we're going to see just in general in E/M healthcare audits. We know that our E/M services are coded based on history exam decision making as our key components.

History: Remember that ancillary staff can document the review of systems and the past family social history. The chief complaint can be inferred but that provider has to document his or her own history present illness. There's been a lot of discussion about this. But yes, the provider does have to document his or her own history of present illness.

You can use a patient completed history form for the review of systems in the past family social history but the provider needs to date and initial that form and refer to it in his documentation as per required evaluation and management documentation guidelines. He can use that form for some period of time after that. But again, he has to date and initial and refer to in the documentation.

History of present illness: Just to remind you of what the eight identifiers in history of present illness are.  CMS has also recently clarified originally when the 1997 documentation guidelines came out. They had the allowance for a provider to use status of three chronic conditions in lieu of giving four, location, quality, severity, duration. Four of those qualifiers, four of those elements.

Originally, we will tell that we could only use that if we follow the 1997 guidelines. CMS clarified a few years ago that you can use that status of three chronic conditions also with the 1995 guidelines. So that's a big help especially in areas like internal medicine, family practice level managing chronic problems.

Review of systems is the history element that is most often lacking. The physician is asking the patient these questions. They're just not documenting the answers.

Now providers can say all other systems negative after they've documented the apartment positives and negatives which means they have to document at least one system as per E and M coding guidelines. At least that’s related system. Just saying review of systems negative is insufficient for complete review of systems.

Past, family, social history: It's pretty self explanatory. The past history, family, social, for higher levels of service (un-aid) one from each of these three areas, family history is the one that is often left out.

Whatever history would have been required to work that patient up would probably be what the exam was. And credit has been given at that level. Can you count one element in both history of present illness and review of systems? And there's a series of letters that went back and forth between the American college of emergency physicians and HCFA, which is of course, is now CMS that said you can use the same information without repeating it.

That's history. Some of the tweaky things on exam, we have the 1997 healthcare guidelines. We have the 1995 guidelines, probably one of the most confusing areas under 1995 guidelines. If we're looking at a problem focused exam, expanded problem focused exam or detail exam, we can count body areas and organ systems.

But when we get to a comprehensive exam, we can only count organ system. So providers must document with that thought in mind, document in terms of organ system as much as possible.

Then the third key component and the one that we non-clinical people had the hardest time with is the medical decision making. It's also the area that providers, physicians and non-physician practitioners like. They discount what they do to a certain extent because they do it all day everyday.

We also have two contributory components, the nature of presenting problem and time.

Nature of presenting problem: It is really an indicator of how sick that patient was when they walked in the door. And it helps provide your medical necessity to support this service. It doesn’t – it's not really decision maker but it could be your tie-breaker that helps determine. Maybe you're looking at the level of service, you're looking at the note, you go “Mm hmm, is the three or is this the four?”

But if you look and see the patient was relatively stable when they came in, otherwise a healthy patient that’s come in with a sinus infection. That might bring you to a lower level. But if you look at this you said, “My goodness. They had a sinus infection but yes, that all these other chronic illnesses.” That might push you to the higher level. This is not necessarily going to be reflected by the diagnosis code.

Time: Now, time is the contributory component that  providers don’t utilize as often as they could. Time is going to be your determining factor when more than half the visit is spent talking to that patient. It can also be used as an average to identify for an audit actually.When we code by time, we count the counseling time, we count the total time, we're going to document both of those times as well as the nature of that counseling visit, what the provider talked about and then you're going to code by the total visit time. But again, time has to be documented keeping in line with the medical billing rules.

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