University of Florida
College of Medicine
Office of Compliance
1995 Documentation Guidelines For Evaluation & Management Services
NOTE: The 1997 E&M Documentation Guidelines contain significant changes in content from the 1995 Guidelines you are viewing here. In those areas where changes were made from the 1995 document they will be noted with either a blue hot-link or a note in red text containing a hot link that you may click on to take you directly to the appropriate section of the 1997 document so that you may review the changes that were made.
I. INTRODUCTION These guidelines are available in a printer optimized Adobe PDF file. Click on the icon to download.
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
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:
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.
III. DOCUMENTATION OF E/M SERVICES
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.
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:
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 Present Illness||Review of Systems (ROS)||
||Type of History|
|Brief||N/A||N/A||Expanded Problem Focused|
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.
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:
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.
An extended HPI consists of four or more elements of the HPI.
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.
For purposes of ROS, the following systems are recognized:
A problem pertinent ROS inquires about the system directly related to the problem(s) identified in the HPI.
An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems.
A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.
PAST, FAMILY AND/OR SOCIAL HISTORY (PFSH)
The PFSH consists of a review of three areas:
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.
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.
B. DOCUMENTATION OF EXAMINATION
NOTE: All of the Documentation of Examination of Past, Family and/or Social History (PFSH) section has been revised and expanded in the 1997 guidelines. Please click here to view these changes in the 1997 document.
The levels of E/M services are based on four types of examination that
are defined as follows:
For purposes of examination, the following body areas are recognized:
For purposes of examination, the following organ systems are recognized:
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.
NOTE: The 1997 Guidelines contain either multi-system or single organ tables that detail specific elements necessary to achieve a particular Level of Examination. The Table of Contents for the 1997 document lists each of these tables which may be viewed by clicking here.
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 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.
data to be reviewed
|Minimal||Minimal or None||Minimal||Straightforward|
Each of the elements of medical decision making is described below.
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.
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
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 occasion the physician who ordered a test may
personally review the image, tracing or specimen to supplement information
from the physician who prepared the test report or interpretation; this
is another indication of the complexity of data being reviewed.
RISK OF SIGNIFICANT COMPLICATIONS, MORBIDITY, AND/OR MORTALITY
The risk of significant complications, morbidity, and/or mortality is
based on the risks associated with the presenting problem(s), the diagnostic
procedure(s), and the possible management options.
The following table may be used to help determine whether the risk of significant complications, morbidity, and/or mortality is minimal, low, moderate, or high. Because the determination of risk is complex and not readily quantifiable, the table includes common clinical examples rather than absolute measures of risk. The assessment of risk of the presenting problem(s) is based on the risk related to the disease process anticipated between the present encounter and the next one.
The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. The highest level of risk in any one category (presenting problem(s), diagnostic procedure(s), or management options) determines the overall risk.
D. DOCUMENTATION OF AN ENCOUNTER DOMINATED BY COUNSELING OR COORDINATION OF CARE
In the case where counseling and/or coordination of care dominates (more
than 50%) of the physician/patient and/or family encounter (face-to-face
time in the office or other outpatient setting or floor/unit time in the
hospital or nursing facility), time is considered the key or controlling
factor to qualify for a particular level of E/M services.
of Medicine, Office of Compliance
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