E&M services: Does your documentation match your work?

Why revisit E&M now? The answer goes straight to the bottom line. Urologists are losing money by not completely documenting and accurately coding for services rendered.

Our company audits hundreds of charts each year to determine whether the services provided by a urologist during a given encounter have been documented, coded, and billed correctly. By reading the documentation, we can usually determine what was actually done. We find three major problems with documentation and coding:

We recommend that a patient questionnaire be used to capture a complete history. During the face-to-face discussion with the patient, write on the form and then sign the form (a must!). One caveat: Medicare has made it clear that the physician has to take and document the history of present illness. Therefore, if dictating, it is best to dictate the history of present illness in your note. If the form is the only documentation, make notes on the history of present illness in your own handwriting.

The physical exam can be captured on a form, as well. We recommend that you develop a form tailored to your style of practice, using the 1995 guidelines for a physical exam. The form should allow you to capture one element in each of the eight different systems, including all elements in the genitourinary system and at least four elements in the gastrointestinal system. With such a form, you are covered if a complete physical exam is medically necessary and, if not, you can capture the appropriate elements for the exam performed.

A complete physical exam is required to charge a level 4 or level 5 consult. If a complete physical exam is not medically necessary, documentation of a level 3 physical examination is common for a male patient. If a physical exam is not performed, mentioning on the form a "well-developed, well-nourished male or female" or collecting vital signs will at least allow a level 1 new patient/consult visit to be charged.

As you document, keep two things in mind. First, you have to document everything that you anticipate counting toward your level of service. Second, the service provided must be medically necessary.

Medical decision making

Because only two of three elements are required for an established patient, the element that is usually not used in the determination of the appropriate code is the physical exam. Therefore, you can do a minimum exam and still charge the appropriate level code according to the level of history and medical decision making (MDM).

A complete history can be achieved by referring back to your initial complete history, documenting the date, and updating the review of symptoms and past medical family and social history. The history of present illness has to be documented at that visit and cannot be updated.

MDM should be the deciding factor in choosing the correct level of care for most established patient visits, and is a required component in all other encounters. Due to limited space, we will discuss only the key points that will assist in appropriately using MDM in coding. Refer to the Medicare guidelines or to the various pocket cards and wall charts for the specific details.