In May, the U.S. Department of Health and Human Services Office of the Inspector General reported that the level of evaluation and management (E/M) codes rose by 48% between 2001 and 2010, and the associated dollar amount increased as well, from $22.7 billion to $33.5 billion. This report opened the door for the Centers for Medicare and Medicaid Services (CMS) to launch audits for medical necessity of E/M services on a nationwide scale.
Many auditors believe that the MDM is what drives an E/M level. Getting to the final result of an encounter has many layers, which is why it is extremely important to document everything that is done during a visit. If it is not documented, it cannot be billed.
Documentation and Guidelines Overview
There are three parts to coding an E/M service—history, exam, and MDM—and two guidelines by which to code—1995 and 1997. Either guideline is permissible to use from visit to visit; however, use only one guideline during an individual visit because there are subtle, yet important, differences in each style.
History documentation: Under the 1995 guidelines, a provider is allowed to document the status of three or more chronic or inactive issues to reach an extended level for the history of present illness, while the 1997 version requires at least four of the eight elements of the illness to be documented:
- Location
- Severity
- Timing
- Modifying factors
- Quality
- Duration
- Context
- Associated signs and symptoms
For more information on documenting a patient history, see “Documentation History in Evaluation and Management Services” in the January 2009 issue of The Rheumatologist (p. 7).
Examination documentation: At first glance, the 1995 version appears to have easier and less tedious documentation requirements, but a practice can leave itself open to an auditor’s interpretation of what is documented. The 1997 version is very specific and rigid in its requirements for documentation. It is broken down into the different organ systems, and each system is broken down by bulleted sections that must be met in order for that organ to count as being examined.
MDM documentation: MDM is the driving force to establish the medical necessity of a visit, and both versions have the same guidelines. MDM comprises three elements:
- Complexity of determining diagnoses or management options;
- Amount and/or complexity of data that needs to be reviewed; and
- Risk of complications and/or morbidity or mortality.
There are four levels of MDM: minimal, limited, multiple, and extensive. To qualify for a level of MDM, two of the three elements in Table 1 must be met.
