Lamon Willis
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During our recent webinar, The Five Problem Areas in E/M Audits, many of you posted really great questions. Unfortunately, we weren’t able to get to all of them live. So, we’re going to tackle all 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.
Answers to Your Most Pressing E/M Audit Questions
Q1. Can you consider the abdomen as a gastrointestinal system in the 1995 guidelines if I count as an organ system?
A1. A statement of abdomen normal or negative alone should not be counted as an organ system. It could be counted as a body area. In order to count abdomen as an organ system, the documentation should include findings related to an organ within the abdomen such as bowel sounds, liver, spleen, etc.
Q2. For hospital subsequent visits, how much information is needed for an expanded problem focused (EPF) interval history?
A2. An interval history is defined as a summary of events that took place since the last E/M encounter in the hospital (usually the day before). If the documentation includes a statement that the patient did well overnight without recurring symptoms, this would be sufficient.
Q3. In the Emergency Department (ED) setting many times the history of present illness (HPI) is recorded by nursing staff. Can a physician say that they reviewed the nurse’s notes for the HPI? Or does the physician have to re-document the HPI?
A3. We recommend you look to your Medicare Administrative Contractor (MAC) for guidance on this. Wisconsin Physicians Services (WPS) Government Healthcare Administrators states “Only the physician can perform the HPI,” and Palmetto GBA goes on to say. “In certain instances, an office or emergency room triage nurse may document pertinent information regarding the chief complaint (CC)/HPI, but this information should be treated as preliminary information. The physician providing this E/M service must consider this information preliminary and needs to document that he or she explore the HPI in more detail.”
WPS: http://www.wpsmedicare.com/j5macpartb/resources/provider_types/2009_0526_emqahistory.shtml
Q4. What is considered additional workup planned for MDM?
A4. See below.
Novitas defines additional workup as “anything that is being done beyond that encounter at that time.” The physician needs to obtain more information for his medical decision making.
Resource: http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf
Q5. If a provider documents time, does that supersede the HPI, Exam and MDM?
A5. The 1995 and 1997 Documentation Guidelines for E/M services state: “If the physician elects to report the level of service based on counseling and/or coordination of care….”. The key word is “elects”, which allows the provider to use either the key components or counseling and/or coordination of care.
Q6. A Review of Systems (ROS) is written by the physician as “unable to obtain due to patient's condition.” Can it be considered a comprehensive ROS?
A6. Yes. Per CMS 1995 and 1997 documentation guidelines for E/M services.
“DG: If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history.”
Audits are essential, but demanding. Learn how we can help you simplify your documentation by watching this short demo of our intelligent auditing software, Audit Manager.
Stay tuned for Part 2 of this series to get more answers to your most pertinent E/M audit questions. And 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.
Questions or Comments?