Documentation of an E/M code requires patient history, the examination, and documenting the decision-making

Has your office ever received a “lack of documentation” denial? What seems to be an insurance company’s standard boilerplate language does have some merit. Most chiropractic offices are weak in documenting the key points of medical necessity and clinical rationale. They are uncertain about exactly what information an insurance carrier is looking for when justifying services.

They are also unaware or misinformed of the appropriate use of some current procedural terminology (CPT) codes. Many simply lack the knowledge of linking all the paperwork into a well-organized file that reads like a John Grisham novel— with a plot, a plan, and a conclusion.

Evaluation and Management (E/M) Services
E/M codes require “key components” to be documented. The higher the number of the code, the more documentation is required. Documentation of an E/M code requires:
    • the history (documented by the patient on his confidential history form and the DC’s notes taken during consultation);
    • the examination (the level of extensiveness must be documented); and
    • the medical decision-making (based on more than just writing a diagnosis, but also documenting the mental exercise of clinical skill used to achieve the diagnosis).

An E/M code represents seven separate components during a visit: history, examination, medical decision-making, counseling, coordination of care, nature of presenting problem, and time. Only the first three are required to be documented to justify the level of code billed. There are “new patient” and “established patient” E/M codes. Established patient E/M services require only two of the three key components to be documented.

A “new patient” is defined as a patient “who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past 3 years,” according to the Amercian Medical Association (AMA) CPT manual

CPT codes for E/M services are principally included in the group of CPT codes, 99201–99499. The codes are divided to describe the place of service (such as office, hospital, home, nursing facility, emergency department, and critical care), the type of service (such as new or initial encounter, follow-up or subsequent encounter, and consultation), and various miscellaneous services (such as prolonged physician service, or care plan oversight service). Because of the nature of E/M services, which mostly represent cognitive services (medical decision-making) based on history and examination, correct coding primarily involves determination of the level of history, examination, and medical decision-making that was performed rather than reporting multiple codes. Normally, only one E/M service code may be reported per day.

The prolonged physician service with direct face-to-face patient contact (CPT codes 99354 and 99355) represents an exception and can be used in conjunction with another E/M code. Other services that are described by codes based on the duration of the encounter, such as critical care services, must be reported alone and not with the prolonged service codes. E/M services, in general, are cognitive services, and significant procedural services are not included in the E/M services. Certain procedural services that arise directly from the E/M service are included as part of the E/M service. For example, counseling and educational services, among other services, are included in E/M services. However, other procedures, such as manipulation and/or therapy, may be billed on the same day.

Contributory Factors
Counseling and coordination of care is defined as “discussion with a patient and/or family concerning one or more of the following”: diagnostic results, impressions or recommendations, prognosis, risks and benefits of treatment options, instructions for treatment or follow-up, importance of compliance with treatment, risk-factor reduction, and patient/family education.

A code should be selected based on the content of the service. Usually, the duration of the visit is an ancillary factor and does not control the level of service to be billed unless more than 50% of the time is spent providing counseling and/or coordination of care.

When the patient’s condition requires counseling and/or coordination of care, and the code is selected on the basis of time, the code selection should be based on the total time of the face-to-face encounter, not just the counseling time. The total time of the encounter and the specific time spent counseling and/or coordinating care should be documented.

Medicare’s “PART” Documentation Requirements
Although Medicare does not pay for E/M services for chiropractors, it does require the documentation of a subluxation to ensure medical necessity of a covered service. A subluxation may be demonstrated by an x-ray or by physical examination. Whether the subluxation is demonstrated by x-ray or by physical examination, certain criteria is expected in the medical record.

Similar to the AMA’s guidelines, Medicare requires documentation during an initial visit to include a specific chief complaint, including the symptoms that caused the patient to seek chiropractic treatment. Medicare also requires a complete history, including:
    • mechanism of trauma;
    • quality and character of problem/symptoms;
    • intensity of symptoms;
    • frequency of symptoms occurring;
    • location and radiation of symptoms;
    • onset of symptoms;
    • duration of symptoms;
    • aggravating or relieving factors of symptoms;
    • prior interventions, treatments including medications; and any secondary complaints.

Depending on the level of E/M billed, certain information regarding a patient’s past family or social history may also be relevant. Documentation regarding past health history, general health statement, prior illnesses, surgical history, prior injuries or traumas, past hospitalizations, and medications should be noted. Any family disease or illnesses that may place the patient at a hereditary risk should also be documented. In some cases, a social history that includes items such as the use of alcohol or tobacco, or diet and exercise may also be appropriate.

However, the most crucial issue in Medicare documentation is known as the “PART” documentation. PART stands for Pain/tenderness, Asymmetry/misalignment, Range-of-motion abnormalities, and Tissue tone.

Documentation of the pain/tenderness element may be evaluated by discussing the location, quality, or intensity of the injury. The asymmetry/misalignment may be identified on a sectional or segmental level by listing which vertebrae are affected. The range-of-motion abnormality may describe changes in active or passive joint movements resulting in an increase or a decrease of sectional or segmental mobility. Documentation regarding changes in tissue-tone characteristics may be of contiguous or associated soft tissue, which includes the skin, fascia, muscle, and/or ligament.

To ensure the medical necessity of treatment, Medicare requires that at least two of the four elements of PART be documented. Also, Medicare requires that one of those two be either the asymmetry/misalignment or the range-of-motion abnormality. Therefore, acceptable documentation of PART would include the “A” with “P,” “R,” or “T”; or the “R” with the “P”, “A,” or “T”; or just the “A” and the “R,” but never just the “P” and the “T.” Medicare makes nothing simple.

The second part of this article will appear in an upcoming issue and will discuss the proper documentation requirements for manipulation and the most common physical therapy services. CP

Ces Soyring, CA, is cofounder of the National Academy of Chiropractic Assistants (www.naca-online.com) and a chiropractic consultant. Contact her at naca_csoyring@yahoo.com.