By: Zach Simpson
As you train your staff on the changes that were recently made regarding evaluation and management coding it is very important to ensure that your staff understands the auditor’s perspective as well. There are four distinct portions of an auditor’s tool when evaluating the documentation guidelines for office/outpatient evaluation and management (E/M) services (99202-99215). The four distinct portions are diagnoses, data, risk, and calculation of medical decision making (MDM). In order to ensure that a provider’s progress note is complete in the auditor’s eyes the provider should ask themselves the following six questions to create the best chances of successfully meeting the auditors expectations:
- Does my progress note contain a medically appropriate history and examination?
- Were my diagnoses addressed appropriately?
- Did I document all orders and data reviewed?
- Were other professionals included in my documentation that I worked with?
- Was an independent historian used?
- Does the documentation support the level of risk I chose?
For the remainder of the article, I am going to dive deeper into each question above so that you, as providers are able to recognize insufficient areas in a provider’s E/M documentation when you perform a self audit to better your practice.
- History and Exam
Due to changes this year with how E/M levels are determined it is still important for providers to perform and document what they consider to be a medically appropriate history and physical despite the fact the focus has shifted to using time or MDM to choose office visit levels. It is still very important to educate your providers on the fact that although the history and physical are no longer key elements in choosing an E/M level, they are still included in the descriptors for codes 99202-99205 and 99212-99215 (i.e., which requires medically appropriate history and/or examination”) and should be fully documented when performed.
- Appropriate Diagnoses
When calculating the overall level of MDM, providers must consider the number and/or complexity of problems addressed during the encounter. The term “addressed” is important: The clinician reporting the service must identify, evaluate, and manage or treat the patient’s problems for the issue to be considered addressed. As evidence the documentation must also reflect a complete evaluation which includes history, exam, diagnostic measures, and treatment.
- Documenting Orders & Data Reviewed
Audits will then look at the data which includes but is not limited to; medical records, tests, and other information that must be obtained, ordered, reviewed, and analyzed during the encounter. Be aware that each unique test, order, and/or document is counted. It is also important to be aware that interpretations of tests that are not separately reported also count.
- Other Professional Involvement
Also included in the data portion of the audit tool is the discussion of management or test interpretation with an appropriate source. This includes an external physician or other qualified healthcare professional, which is defined in the AMA guidelines as an individual who is not in the same group practice or is a different specialty or subspecialty, including licensed professionals practicing independently. This may also be a facility or organizational provider such as a hospital, nursing facility, or home healthcare agency. Appropriate sources include non-healthcare professionals who are involved in the management of the patient (for example, lawyers, parole officers, case managers, and teachers). Discussions with family or caregivers are not included.
- Independent Historians
In addition to the information that was obtained from the patient, providers may also rely on independent historians such as a parent, spouse, guardian, surrogate, or witness to provide additional history regarding the patient.
The data elements described above in numbers three through five are then counted and/or categorized and the combination is used to determine a level for the data portion in the audit tool.
- Is The Risk Level Supported
Morbidity risk is the third section of the audit tool that is taken into consideration by auditors. Morbidity is defined as a state of illness or functional impairment that is expected to be of substantial duration during which function is limited, quality of life is impaired, or there is organ damage that may not be transient despite treatment. The level of risk is based upon the consequences of the problem(s) for MDM purposes at the encounter when appropriately treated.
Risk levels are defined as minimal, low, moderate, and high. Examples of moderate risk include prescription drug management and diagnosis/treatment significantly limited by social determinants of health such as housing and food insecurities. Examples of high risk include drug therapy requiring intensive monitoring for toxicity and decisions regarding hospitalization. Auditors will look in the documentation for content that supports the level of risk.
Final Calculations
The final MDM levels are determined after individual levels for the categories of diagnoses, data, and risk are reviewed to determine on if the visit documentation meets or exceeds two of three elements for a particular level of MDM.
Additional Resources
To further aid in your practice’s E/M Office or Other Outpatient Audit (99202-99215) the American Association of Professional Coders “AAPC” has created an easy to use reliable Audit Worksheet that can be found here. If any further clarification is needed remember it is always best to reach out to a healthcare attorney.