1995 Documentation Guidelines For

Summary

1995 DOCUMENTATION GUIDELINES
FOR EVALUATION AND MANAGEMENT SERVICES
I. INTRODUCTION
WHAT IS DOCUMENTATION AND WHY IS IT IMPORTANT?
Medical record documentation is required to record pertinent facts, findings, and
observations about an individual's health history including past and present illnesses,
examinations, tests, treatments, and outcomes. The medical record chronologically
documents the care of the patient and is an important element contributing to high
quality care. The medical record facilitates:
the ability of the physician and other healthcare professionals to evaluate and
plan the patient’s immediate treatment, and to monitor his/her healthcare over
time;
communication and continuity of care among physicians and other healthcare
professionals involved in the patient's care;
accurate and timely claims review and payment;
appropriate utilization review and quality of care evaluations; and
collection of data that may be useful for research and education

An appropriately documented medical record can reduce many of the "hassles"
associated with claims processing and may serve as a legal document to verify the care
provided, if necessary

WHAT DO PAYERS WANT AND WHY?
Because payers have a contractual obligation to enrollees, they may require reasonable
documentation that services are consistent with the insurance coverage provided. They
may request information to validate:
the site of service;
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the medical necessity and appropriateness of the diagnostic and/or therapeutic
services provided; and/or
that services provided have been accurately reported

II. GENERAL PRINCIPLES OF MEDICAL RECORD DOCUMENTATION
The principles of documentation listed below are applicable to all types of medical and
surgical services in all settings. For Evaluation and Management (E/M) services, the
nature and amount of physician work and documentation varies by type of service,
place of service and the patient's status. The general principles listed below may be
modified to account for these variable circumstances in providing E/M services

1. The medical record should be complete and legible

2. The documentation of each patient encounter should include:
reason for the encounter and relevant history, physical examination findings,
and prior diagnostic test results;
assessment, clinical impression, or diagnosis;
plan for care; and
date and legible identity of the observer

3. If not documented, the rationale for ordering diagnostic and other ancillary
services should be easily inferred

4. Past and present diagnoses should be accessible to the treating and/or
consulting physician

5. Appropriate health risk factors should be identified

6. The patient's progress, response to and changes in treatment, and revision of
diagnosis should be documented

7. The CPT and ICD-9-CM codes reported on the health insurance claim form or
billing statement should be supported by the documentation in the medical record

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II. DOCUMENTATION OF E/M SERVICES
This publication provides definitions and documentation guidelines for the three key
components of E/M services and for visits which consist predominately of counseling or
coordination of care. The three key components--history, examination, and medical
decision making--appear in the descriptors for office and other outpatient services,
hospital observation services, hospital inpatient services, consultations, emergency
department services, nursing facility services, domiciliary care services, and home
services. While some of the text of CPT has been repeated in this publication, the
reader should refer to CPT for the complete descriptors for E/M services and
instructions for selecting a level of service. Documentation guidelines are identified
by the symbol • DG

The descriptors for the levels of E/M services recognize seven components which are
used in defining the levels of E/M services. These components are:
history;
examination;
medical decision making;
counseling;
coordination of care;
nature of presenting problem; and
time

The first three of these components (i.e., history, examination and medical decision
making) are the key components in selecting the level of E/M services. An exception to
this rule is the case of visits which consist predominantly of counseling or coordination
of care; for these services time is the key or controlling factor to qualify for a particular
level of E/M service

For certain groups of patients, the recorded information may vary slightly from that
described here. Specifically, the medical records of infants, children, adolescents and
pregnant women may have additional or modified information recorded in each history
and examination area

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As an example, newborn records may include under history of the present illness (HPI)
the details of mother’s pregnancy and the infant's status at birth; social history will focus
on family structure; family history will focus on congenital anomalies and hereditary
disorders in the family. In addition, information on growth and development and/or
nutrition will be recorded. Although not specifically defined in these documentation
guidelines, these patient group variations on history and examination are appropriate

A. DOCUMENTATION OF HISTORY
The levels of E/M services are based on four types of history (Problem Focused,
Expanded Problem Focused, Detailed, and Comprehensive). Each type of history
includes some or all of the following elements:
Chief complaint (CC);
History of present illness (HPI);
Review of systems (ROS); and
Past, family and/or social history (PFSH)

The extent of history of present illness, review of systems, and past, family and/or social
history that is obtained and documented is dependent upon clinical judgment and the
nature of the presenting problem(s)

The chart below shows the progression of the elements required for each type of
history. To qualify for a given type of history, all three elements in the table must be
met. (A chief complaint is indicated at all levels.)
History of Review of Systems Past, Family, Type of History
Present Illness (ROS) and/or Social
(HPI) History (PFSH)
Brief N/A N/A Problem
Focused
Brief Problem Pertinent N/A Expanded
Problem
Focused
Extended Extended Pertinent Detailed
Extended Complete Complete Comprehensive
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DG: 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 the present illness

DG: A ROS and/or a PFSH obtained during an earlier encounter does not need
to be re-recorded if there is evidence that the physician reviewed and updated
the previous information. This may occur when a physician updates his/her own
record or in an institutional setting or group practice where many physicians use
a common record. The review and update may be documented by:
o describing any new ROS and/or PFSH information or noting there has been
no change in the information; and
o noting the date and location of the earlier ROS and/or PFSH

DG: The ROS and/or PFSH may be recorded by ancillary staff or on a form
completed by the patient. To document that the physician reviewed the
information, there must be a notation supplementing or confirming the
information recorded by others

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

Definitions and specific documentation guidelines for each of the elements of history are
listed below

CHIEF COMPLAINT (CC)
The CC is a concise statement describing the symptom, problem, condition, diagnosis,
physician recommended return, or other factor that is the reason for the encounter

DG: The medical record should clearly reflect the chief complaint

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HISTORY OF PRESENT ILLNESS (HPI)
The HPI is a chronological description of the development of the patient's present illness
from the first sign and/or symptom or from the previous encounter to the present. It
includes the following elements:
location;
quality;
severity;
duration;
timing;
context;
modifying factors; and
associated signs and symptoms

Brief and extended HPIs are distinguished by the amount of detail needed to
accurately characterize the clinical problem(s)

A brief HPI consists of one to three elements of the HPI

DG: The medical record should describe one to three elements of the present
illness (HPI)

An extended HPI consists of four or more elements of the HPI

DG: The medical record should describe four or more elements of the present
illness (HPI) or associated comorbidities

REVIEW OF SYSTEMS (ROS)
A ROS is an inventory of body systems obtained through a series of questions seeking
to identify signs and/or symptoms which the patient may be experiencing or has
experienced

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For purposes of ROS, the following systems are recognized:
Constitutional symptoms (e.g., fever, weight loss)
Eyes
Ears, Nose, Mouth, Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary (skin and/or breast)
Neurological
Psychiatric
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic
A problem pertinent 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

An extended ROS inquires about the system directly related to the problem(s) identified
in the HPI and a limited number of additional systems

DG: The patient's positive responses and pertinent negatives for two to nine
systems should be documented

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A complete ROS inquires about the system(s) directly related to the problem(s)
identified in the HPI plus all additional body systems

DG: At least ten organ systems must be reviewed. 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

PAST, FAMILY, AND/OR SOCIAL HISTORY (PFSH)
The PFSH consists of a review of three areas:
past history (the patient's past experiences with illnesses, operations, injuries and
treatments);
family history (a review of medical events in the patient's family, including
diseases which may be hereditary or place the patient at risk); and
social history (an age appropriate review of past and current activities)

For the categories of subsequent hospital care, follow-up inpatient consultations and
subsequent nursing facility care, CPT requires only an "interval" history. It is not
necessary to record information about the PFSH

A pertinent PFSH is a review of the history area(s) directly related to the problem(s)
identified in the HPI

DG: At least one specific item from any of the three history areas must be
documented for a pertinent PFSH

A complete PFSH is of a review of two or all three of the PFSH history areas,
depending on the category of the E/M service. A review of all three history areas is
required for services that by their nature include a comprehensive assessment or
reassessment of the patient. A review of two of the three history areas is sufficient for
other services

DG: At least one specific item from two of the three history areas must be
documented for a complete PFSH for the following categories of E/M services:
office or other outpatient services, established patient; emergency department;
subsequent nursing facility care; domiciliary care, established patient; and home
care, established patient

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DG: At least one specific item from each of the three history areas must be
documented for a complete PFSH for the following categories of E/M services:
office or other outpatient services, new patient; hospital observation services;
hospital inpatient services, initial care; consultations; comprehensive nursing
facility assessments; domiciliary care, new patient; and homecare, new patient

B. DOCUMENTATION OF EXAMINATION
The levels of E/M services are based on four types of examination that are defined as
follows:
Problem Focused -- a limited examination of the affected body area or organ
system

Expanded Problem Focused -- a limited examination of the affected body area
or organ system and other symptomatic or related organ system(s)

Detailed -- an extended examination of the affected body area(s) and other
symptomatic or related organ system(s)

Comprehensive -- a general multi-system examination or complete examination
of a single organ system

For purposes of examination, the following body areas are recognized:
Head, including the face
Neck
Chest, including breasts and axillae
Abdomen
Genitalia, groin, buttocks
Back, including spine
Each extremity
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For purposes of examination, the following organ systems are recognized:
Constitutional (e.g., vital signs, general appearance)
Eyes
Ears, nose, mouth, and throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic/lymphatic/immunologic
The extent of examinations performed and documented is dependent upon clinical
judgment and the nature of the presenting problem(s). They range from limited
examinations of single body areas to general multi-system or complete single organ
system examinations

DG: Specific abnormal and relevant negative findings of the examination of the
affected or symptomatic body area(s) or organ system(s) should be documented

A notation of "abnormal” without elaboration is insufficient

DG: Abnormal or unexpected findings of the examination of the unaffected or
asymptomatic body area(s) or organ system(s) should be described

DG: A brief statement or notation indicating "negative" or "normal" is sufficient to
document normal findings related to unaffected area(s) or asymptomatic organ
system(s)

DG: The medical record for a general multi-system examination should include
findings about 8 or more of the 12 organ systems

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C. DOCUMENTATION OF THE COMPLEXITY OF MEDICAL DECISION MAKING
The levels of E/M services recognize four types of medical decision making (straight-
forward, low complexity, moderate complexity, and high complexity). Medical decision
making refers to the complexity of establishing a diagnosis and/or selecting a
management option as measured by:
the number of possible diagnoses and/or the number of management options
that must be considered;
the amount and/or complexity of medical records, diagnostic tests, and/or other
information that must be obtained, reviewed, and analyzed; and
the risk of significant complications, morbidity, and/or mortality, as well as
comorbidities associated with the patient's presenting problem(s), the diagnostic
procedure(s) and/or the possible management options

The chart below shows the progression of the elements required for each level of
medical decision making. To qualify for a given type of decision making, two of the
three elements in the table must be either met or exceeded

Number of Amount and/or Risk of Type of
diagnoses or complexity of data complications decision making
management to be reviewed and/or morbidity
options or mortality
Minimal Minimal or None Minimal Straightforward
Limited Limited Low Low Complexity
Multiple Moderate Moderate Moderate
Complexity
Extensive Extensive High High
Complexity
Each of the elements of medical decision making is described on the following page

NUMBER OF DIAGNOSES OR MANAGEMENT OPTIONS
The number of possible diagnoses and/or the number of management options that must
be considered is based on the number and types of problems addressed during the
encounter, the complexity of establishing a diagnosis and the management decisions
that are made by the physician

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Generally, decision making with respect to a diagnosed problem is easier than that for
an identified but undiagnosed problem. The number and type of diagnostic tests
employed may be an indicator of the number of possible diagnoses. Problems which
are improving or resolving are less complex than those which are worsening or failing to
change as expected. The need to seek advice from others is another indicator of
complexity of diagnostic or management problems

DG: For each encounter, an assessment, clinical impression, or diagnosis should
be documented. It may be explicitly stated or implied in documented decisions
regarding management plans and/or further evaluation

For a presenting problem with an established diagnosis the record should
reflect whether the problem is: a) improved, well controlled, resolving or
resolved; or, b) inadequately controlled, worsening, or failing to change as
expected

For a presenting problem without an established diagnosis, the assessment
or clinical impression may be stated in the form of a differential diagnoses or
as "possible,” "probable,” or "rule out” (R/O) diagnoses

DG: The initiation of, or changes in, treatment should be documented. Treatment
includes a wide range of management options including patient instructions,
nursing instructions, therapies, and medications

DG: If referrals are made, consultations requested or advice sought, the record
should indicate to whom or where the referral or consultation is made or from
whom the advice is requested

AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWED
The amount and complexity of data to be reviewed is based on the types of diagnostic
testing ordered or reviewed. A decision to obtain and review old medical records and/or
obtain history from sources other than the patient increases the amount and complexity
of data to be reviewed

Discussion of contradictory or unexpected test results with the physician who performed
or interpreted the test is an indication of the complexity of data being reviewed. On
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II. GENERAL PRINCIPLES OF MEDICAL RECORD DOCUMENTATION The principles of documentation listed below are applicable to all types of medical and surgical services in all …

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Frequently Asked Questions

What is medical record documentation?

Medical record documentation is required to record pertinent facts, findings, and observations about an individual's health history including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high quality care.

What documentation should be included in a patient encounter?

The documentation of each patient encounter should include: reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results; assessment, clinical impression, or diagnosis; plan for care; and

What are the em worksheet 1995 guidelines for auditors?

E/M DOCUMENTATION AUDITORS’ WORKSHEET 1995 Guidelines Member Last Name or Identifying Number Provider Name Date of Service Procedure Code(s) Reported †Auditor Agrees Auditor Disagrees Code Assigned by Auditor Record Audited by Date E/M Documentation Auditors’ Instructions Refer to data section (table below) in order to quantify.

Can the department cite or use guidance that is not posted?

The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.