Ask an Auditor Series: Common Errors in Evaluation and Management (E/M) Audits Frequently Asked Questions (Part 4)

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, Part 2, and Part 3.

Q1. In relation to E/M billing, is preoperative clearance in and of itself a valid reason for a consult or does there need to be another problem (i.e. diabetes)?

A1. Please note that a preoperative consultation is eligible under Medicare as long as the consultation criteria and medical necessity criteria are met. These guidelines are found in the CMS Manual System, publication 100-02, Claims Processing Manual, Chapter 15, Section 30 (C), which states, A consultation is reimbursable when it is a professional service furnished a patient by a second physician or consultant at the request of the attending physician. Such a consultation includes the history and examination of the patient as well as the written report, which is furnished to the attending physician for inclusion in the patient’s permanent medical record.

-NHIC E/M FAQs

Q2. What are the amount of bullets required in 1997 guidelines for a detailed exam versus a comprehensive exam?

A2. In the Medicare 1997 E/M Guidelines under, “General Multi-System Examinations,” you will find the following:

“Detailed Examination – should include at least six organ systems or body areas. For each system/area selected, performance and documentation of at least two elements identified by a bullet (•) is expected.

Alternatively, a detailed examination may include performance and documentation of at least twelve elements identified by a bullet (•) in two or more organ systems or body areas.”

And for a Comprehensive Examination the guidelines list the following:

“Comprehensive Examination – should include at least nine organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet (•) should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least two elements identified by a bullet is expected.”

For a Detailed Single Organ System Examination you will find the following:

“Detailed Examination – examinations other than the eye and psychiatric examinations should include performance and documentation of at least twelve elements identified by a bullet (•), whether in a box with a shaded or unshaded border.

Eye and psychiatric examinations should include the performance and documentation of at least nine elements identified by a bullet (•), whether in a box with a shaded or unshaded border.”

Q3. Can the ROS be taken from the HPI?

A3. The HPI is a chronological description of the development of the patient’s present illness from the first sign and symptom or from the previous encounter to the present. The ROS is the inventory of body systems through questions to help identify signs and/or symptoms related to the HPI. ROS are the questions you ask based on the information given by the patient in the HPI and may overlap.

-NHIC E/M FAQs

Q4. Can the History of Present Illness (HPI) elements be counted for both the Chief Complaint (CC) and the associated signs/symptoms? For instance, a patient presents with chest (location) pain (CC) that she has had for 3 days (duration). She also experiences shortness of breath (associated signs/symptoms) when walking up the stairs (context).

A4. Yes. According to the 1995 and 1997 E/M documentation guidelines, "The CC, ROS, and PFSH may be listed as separate elements of history or they may be included in the description of the history of present illness.”

-WPS E/M FAQs

Q5. Our office requests that our patients complete a form by checking yes or no regarding their medications, medical history, family history, and social history information. Can we include this information as documentation of the Past, Family, Social History (PFSH) and Review of Systems (ROS)?

A5. Yes, this information may be used if the physician notes that he has reviewed the form. It is also appropriate for the physician to note in the medical records any additional information obtained during the face-to-face encounter.

-Novitas E/M FAQs

Q6. A patient comes in with stomach pain and states has been on/off for 2 days and is 5 out of 10 pain, no vomiting or diarrhea. There is debate whether negative sign and symptoms should actually be used as a ROS. Can the no vomiting or diarrhea be used as a sign or symptom as this is negative or would it be used as a ROS?

A6. In both the Medicare 1995 and 1997 E/M documentation guidelines it states the following information:

(The) “ROS inquires about the system directly related to the problem(s) identified in the HPI.

DG: The patient's positive responses and pertinent negatives for the system related to the problem should be documented.”

For additional questions, submit them in the comment section below. We’ll answer them as quickly as possible in a future, Ask an Auditing Expert, post.

If you would like to see the webinar that inspired this blog post series, we welcome you to watch the on-demand recording by clicking the button below: