Ask an Auditor Series: Common Errors in Evaluation and Management (E/M) Audits Frequently Asked Questions (Part 3)

Many of you posted some great questions during our webinar, The Five Problem Areas in E/M Audits. Unfortunately, we weren’t able to get to all of them. So, we’ll be tackling your most pressing questions in this ongoing blog series that we're calling "Ask an Auditor."

In this series, I will answer your most frequently asked questions related to evaluation and management audits. After all, we’re here to support you on your superstar journey to master all things auditing. 

New to this series? Here you’ll find Part 1 and Part 2.

Q1. Is the documentation “all other systems negative” for Review Of Systems sufficient enough to get the higher level of service?

A1. A higher level of history may be possible if the other elements of the history such as the HPI and Past, Family, and Social history are met. A higher level of service, as in an E/M code, cannot be determined without knowing the levels of the other key components of the E/M.

Q2. What is meant by "Status of chronic conditions”?

A2. In 1997, the Evaluation and Management (E/M) Guidelines were enhanced under the History of Present Illness (HPI) section of the 1995 score sheet to include the patient's chronic conditions the practitioner is following or in which an exacerbation may have occurred resulting in the chief complaint and the reason for the patient encounter. The documentation in the patient's medical record must clearly state a status of the chronic condition in order to meet the requirement under the History HPI Status of 1, 2, or 3 Chronic Conditions on the 1995 score sheet. An example could be hypertension - stable on Atenolol.

Reference - Novitas E/M FAQs

Q3. When scoring medical records, how is medical necessity considered?

A3. All services under Medicare must be reasonable and necessary as defined in Title XVIII of the Social Security Act, Section 1862(a)(1)(A). This section states, no payment may be made for any expenses incurred for items or services, which are not reasonable and necessary for the diagnosis or treatment of injury or to improve the functioning of a malformed body member. Therefore, medical necessity is the first consideration in reviewing all services.

Reference - Novitas E/M FAQs

Q4. For the Review of Systems, can the physician reference a sheet that he has in the patient's chart where the physician checked off items?

A4. Yes. However, if medical records are requested, the sheet must be submitted with all of the other documentation for that date of service. Otherwise, no credit can be given for the information on the check-off sheet. 

Reference - Novitas E/M FAQs 

Q5. My patient visits are dominated primarily by counseling and coordination of care. How do I bill for this type of patient visit? 

A5. When counseling and/or coordination of care dominate more than 50% of the time a physician spends with a patient during an evaluation and management (E/M) service then time may be considered as the controlling factor to qualify the E/M service for a particular level of care. If the physician elects to report the level of care based on counseling and/or coordination of care, then a number of factors must be documented in the patient's medical record. The following must be documented in the patient's medical record in order to report an E/M service based on time: 

  • The total length of time of the E/M visit; 
  • Evidence that more than half of the total length of time of the E/M visit was spent in counseling and coordinating of care; and 
  • The content of the counseling and coordination of care provided during the E/M visit. 

Reference - Novitas E/M FAQs 

Q6. Under limited circumstances, could the term “noncontributory” be used as appropriate documentation to support the review of systems (ROS) and family history sections of the history component of an evaluation and management service (E/M)? 

A6. It is understood that there may be circumstances where the term "noncontributory" may be appropriate documentation when referring to the ROS and/or family history sections of the history component of an E/M service. Under the E&M documentation guidelines, it is noted that, "those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented." The use of the term "noncontributory" may be permissible documentation when referring to the remaining negative review of systems. The term "noncontributory" may also be appropriate documentation when referring to a patient's family history during an E/M visit, if the family history is not pertinent to the presenting problem. 

Reference - Novitas E/M FAQs 

Stay tuned for Part 4 of this series to get more answers to your most pertinent E/M audit questions. If you have any additional questions, please submit them in the comment section below and we’ll get to them in a future Ask an Auditing Expert post.

Also, if you would like to watch a free, on-demand recording of the webinar that inspired this blog post series, you can do so by clicking the button below:

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