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Medical Record Documentation for E/M Services

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 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.

Documentation of History

The levels of E/M services are based on four levels of history (Problem Focused, Expanded Problem Focused, Detailed, and Comprehensive). Each type of history includes some or all of the following elements: Chief complaint (CC) History of present illness (HPI) Review of systems (ROS) and Past, family, and/or social history (PFSH). The extent of the history of present illness, review of systems, and past, family and/or social history that is obtained and documented is dependent upon clinical judgment and the nature of the presenting problem(s). The chart below shows the progression of the elements required for each type of history. To qualify for a given type of history all three elements in the table must be met. (A chief complaint is indicated at all levels.)

History of Present Illness (HPI)

Review of Systems (ROS)

Past, Family, and/or
Social History (PFSH)

Type of History

Brief N/A N/A Problem Focused
Brief Problem Problem Pertinent  N/A Focused Expanded Problem
Extended Extended Pertinent  Detailed
Extended Complete  Complete Comprehensive

Documentation of Examination

The levels of E/M services are based on four types of examination:

  • Problem Focused – a limited examination of the affected body area or organ system.
  • Expanded Problem Focused – a limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s).
  • Detailed – an extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s).
  • Comprehensive – a general multi-system examination, or complete examination of a single organ system and other symptomatic or related body area(s) or organ system(s).

A general multi-system examination or a single organ system examination may be performed by any physician, regardless of specialty. The type (general multisystem or single organ system) and content of examination are selected by the examining physician and are based upon clinical judgment, the patient’s history, and the nature of the presenting problem(s).

Documentation for 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

The chart below shows the progression of the elements required for each level of medical decision making. To qualify for a given type of decision making, two of the three elements in the table must be either met or exceeded.

Number of diagnoses or management options

The amount and/or complexity of data to be reviewed

Risk of complications and/or morbidity or mortality

Type of decision making

Minimal Minimal or None  Minimal Straightforward
Limited Limited Low Low Complexity
Multiple Moderate Moderate Moderate Complexity
 Extensive Extensive  High  High Complexity

Documentation of an Encounter Dominated by Counselling/Coordination of Care

In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face time in the office or other or outpatient setting, floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M services. If the physician elects to report the level of service based on counseling and/or coordination of care, the total length of time of the encounter (face-to-face or floor time, as appropriate) should be documented and the record should describe the counseling and/or activities to coordinate care.

Reference:

Evaluation and Management Services

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