Earlier this month RACmonitor informed us of the new U.S. Department of Health and Human Services Office of Inspector General (HHS OIG) release encouraging the Centers for Medicare & Medicaid Services (CMS) to place more scrutiny on evaluation and management (E&M) services, with the suggestion based on the staggering statistics surrounding improper payments for these services.

E&M services often are selected incorrectly due to the level assigned being based on documentation content alone. Additionally, electronic health record (EHR) systems that suggest levels of service are utilizing documentation content alone.

Without a clear understanding of medical necessity and the complexity of the patient’s condition as documented within the medical record, the proper level of service cannot be assigned. The big picture that often is missed is that medical necessity goes hand-in-hand with what should be documented as part of the encounter. For example, when we consider CPT code 99212, we envision a patient with a minimal problem.

The documentation guidelines correlate this with only one HPI element, one system on exam, and a straightforward interpretation of medical decision-making, but when we envision a CPT code 99215 encounter, we think of a patient who presents with a problem of high severity, meaning the documentation requirements are dramatically increased (such a patient requiring four HPI, 10 ROS, two PFSH, a comprehensive exam, and a high complexity plan of care). 

When considering the entire body of the patient encounter, including progress notes, we have the core documentation elements to consider. These consist of history, physical examination, and the medical decision-making process. Each of these key components can be broken down further into specific issues we must contemplate. When considering the entire progress note, we can think of these components as being used to construct a pyramid, which should be used as a guide to demonstrate proper medical necessity through the expansion of the documentation within each of the components.

The top region of our pyramid begins with the history. We are so used to thinking of the history merely by identifying the elements associated within it that we fail to break it down and fully explore what it really tells us about the patient. A properly constructed history should identify the following:

  • The patient’s problem (chief complaint)
  • How long the patient has had the problem, along with the symptoms the patient is experiencing because of the problem
  • How other organ systems are being affected by the chief complaint
  • Historical concerns that could affect the treating of the problem or points of consideration on how the current problem may affect historical concerns of the patient

Utilizing this approach, compared to the individual classification of the elements, suddenly makes the history come together to better explain the growing documentation requirements with each increased level of service. The history should define the severity of the patient’s problem (according to the patient).

The point from which our pyramid will be developed begins with the chief complaint. The chief complaint is very important, as it is the core defining point from which the entire note will be judged. Therefore, not including a clear and concise chief complaint may limit the growth of the documentation. If a specific chief complaint is not documented, the medical necessity of the entire visit could be affected.

Our pyramid expands as we include the history of present illness, which defines the symptoms the patient is experiencing as reflected by his or her chief complaint. The history of present illness is a key element of medical necessity, as it has the ability to specifically define how the patient is being affected. Think of the elements within the history of present illness, such as the context and severity of the problem, how long the patient has had the problem, and how the problem began. Properly addressing these issues within the documentation can better explain the complexity that will be involved with taking care of the patient and his or her specific problem to help illustrate the medical necessity of the encounter.

Expanding our history more by moving on to the review of systems, we now take the patient’s problem and find out to what extent it has compromised other organ systems. Such documentation too often is represented by a list of symptoms the patient can say he or she is or is not experiencing; but this truly illuminates how the problem is affecting the rest of the patient’s body (which is why many Medicare carriers allow the “all other systems are negative” statement to be counted as a complete review of systems). That statement is the provider’s way of documenting that when evaluating the review of systems as compared to the chief complaint, there are no other organ systems being affected. When the documentation is constructed in this manner, a higher level of severity is noted when other organ systems are being affected.

The past, family, and social history often are documented as though they are merely placeholders in the documentation, but they truly bring value to the documentation of the patient’s severity. Knowing the patient’s past medical concerns, family health risks, and day-to-day exposures will better assist the provider in delivering the best care possible, as well as exposing any concerns from the history that may affect the treatment of the problem (all of which could have an impact on the medical complexity of the encounter).

The middle of our documentation pyramid is constructed with the exam of the patient. The exam is best viewed when you consider it as the primary objective, marking the hands-on work of the encounter. The provider takes the history information and reviews it for the severity of the patient’s condition, then uses the exam to form an opinion on how to best treat the patient. Each organ system examined should be fully documented to the extent of the exam performed. In other words, if the provider examines a hurt knee and examines the well knee for comparison, the documentation should report the findings as they pertain to both knees. Far too often the well knee is not documented, but this helps to define the medical necessity further by showing noted deficiencies revealed in the comparison. Template exams that contain an array of negative findings can distract from the medical necessity of the exam findings pertinent to the affected body areas/organ systems, however. Keep in mind that the exam requirements for a 99214 (according to 1995 guidelines), require only two organ systems being affected, with the conditions documented in a detailed or extended fashion (which by virtue of the severity of a problem that supports a 99214 would be representative of this guidance). So all of those extra organ systems that are full of normal findings do not provide any value to the documentation, but in some instances they may diminish the medical complexity.

The base of the pyramid is an analysis of the patient. It is the physician taking the patient’s problem and stated severity (history), then comparing them with the findings of the exam. This is done to produce an analysis of the patient’s problem that is reflective of the patient’s severity, according to the provider, and a plan of how to treat the problem. In an encounter constructed in this model, the analysis and plan of care naturally will grow in content as the medical complexity grows. All the while, documentation should be made more complete to better meet the relevant documentation guidelines. Within the medical decision-making, the provider should include content that connects the dots of the entire evaluation by pulling together a brief narrative (1-3 sentences) incorporating history information that may have an impact and the work performed by the provider through the assessment process (such as reviewing records and ordering tests/procedures). Often the labor portion of the plan of care is not documented fully to show the work that the provider rendered during the encounter; ensuring that this information is included will better display medical necessity.

Considering the documentation carefully and approaching it in this way meets the CMS recommendation that the provider is to “paint a portrait” of the patient and his or her condition(s). It drastically reduces the likelihood that an auditor, another provider, an insurance company, or any reader of the encounter (who may have little to no experience in the relevant specialty) will misinterpret the facts or question medical necessity.

A doctor I recently trained interpreted this process with this one line: “oh, so you just want me to document my thought process.” Providers who document in this manner will find that no matter how much scrutiny is placed on their records, medical necessity will be found in a clear format, meaning they will not be as concerned with threats of increasing audits.

About the Author

Shannon DeConda is the founder and president of the National Alliance of Medical Auditing Specialists (NAMAS) as well as the President of Coding & Billing Services and a Partner at DoctorsManagement, LLC. Ms. DeConda has more than 16 years of experience as a multi-specialty auditor and coder. She has helped coders, medical chart auditors, and medical practices optimize business processes and maximize reimbursement by identifying lost revenue. Since founding NAMAS in 2007, Ms. DeConda has developed the NAMAS CPMA® Certification Training, written the NAMAS CPMA® Study Guide, and launched a wide variety of educational products and web-based educational tools to help coders, auditors, and medical providers improve their efficiencies.

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