Five Documentation Habits Providers Can Use Implement to Improve Evaluation & Management (E/M) Scoring

The changes made to E/M service reporting over the past few years have caused a resurgence of coder and provider education, as well as documentation practice and template reviews, not seen since implementation of the new ICD-10-CM code set back in 2015. While many of us were busy trying to get a handle on the 2021 changes, the American Medical Association (AMA) released the 2021 CPT® Errata and Technical Corrections, on March 19, 2021, which included a significant amount of changes requiring additional education and process revisions. On March 1, 2023, the AMA published the 2023 CPT® Errata and Technical Corrections pertaining to the most recent 2023 E/M changes, worthy of a good review and mention to coders and providers alike.

In consideration of the overall changes made to E/M service documentation, coding, and reporting guidelines, we have identified the following five minor changes providers can make now that can have a significant impact on E/M code assignment and reimbursement.

1. Document a Medically Appropriate History and Examination
   The new guidelines do not use history and examination in the scoring process used to identify the E/M service level, but telling the patient’s story is vital to understanding severity, causation, and associated patient risk factors. Identifying any social determinants of health (SDoH) that may impact the patient’s ability to complete provider treatment recommendations is such a vital aspect of patient care that many payers are offering resource options for patients that need them to ensure positive outcomes. And finally, the patient’s history, helps to support medical necessity for the provider’s ordered treatment. 
   
   
2. Specify the Status of All Problems Addressed During the Encounter
   One of the biggest and most consistent provider documentation issues is the failure to document the current status of the problem(s) that were addressed during the encounter. The E/M MDM element “Number and Complexity of Problems Addressed” allows scoring of any problems addressed during the encounter, but when providers fail to document their view of the status of the condition, this decision is left to coders or queries. Coders do not always have access to query providers, and being left to determine the status of a condition based on the documentation alone often results in a lower severity or status. Often just ensuring providers know how this MDM element is scored can make all the difference in their documentation efforts. Consider adding a note for providers at their dictation station or on the back of their device, or if an option, and if at all possible, have a quick 5-minute training session on these five minor changes they can make to improve coding outcomes. The severity of the problem or status options related to scoring problems include:
   
   

   Problem	Status at Encounter	Description
   Minimal Problem	May not have needed the assistance of a physician/QHP
   Self-Limited or Minor Problem	Runs a definite and prescribed course Transient in nature Not likely to permanently alter health status of patient Generalized symptoms (e.g, fever, body aches, fatigue) in minor illness
   Acute Problem(s)	Low
   	Stable, acute illness	Recent/New. Treatment already initiated. Resolving/improving
   	Uncomplicated illness/injury (outpatient)	Recent/New/Short-term. Low risk morbidity, low/no mortality risk. Treatment considered. Full recovery expected w/o functional impairment OR self-limited/minor problem not resolving prescribed treatment course.
   	Uncomplicated illness/injury (hospital)	Recent/New/Short-term. Low risk morbidity, low/no mortality risk. Treatment required & delivered inpatient/observation setting. Full recovery expected.
   	Moderate
   	Illness with systemic symptoms	Systemic symptoms (single or multiple systems (not generalized symptoms of a minor illness). High risk of morbidity without treatment.
   	Complicated injury	Requires evaluation of systems not directly injured. Extensive injury. Multiple treatment options and/or associated risk of morbidity.
   	High
   	Poses threat to life or bodily function	Near-term threat without treatment. Symptoms of severity representing a significantly probable condition that poses threat.
   Chronic Problem(s) Expected duration 1 year or until death Stability defined by individual treatment goals	Low
   	Stable	At patient treatment goal. No short-term threat to life/function. Risk of morbidity w/o treatment is high
   	Moderate
   	Exacerbated progressing, side effects of treatment	Not at goal. Poorly controlled, even if condition has not changed for worse is considered not stable. Progressing w/intent to control. Requires additional treatment/care/attention/changes
   	High
   	Severe exacerbation, severe progression, severe side effects of treatment	Significant risk of morbidity; may require escalation in level of care.
   	Poses threat to life or bodily function	Near-term threat without treatment. Symptoms of severity representing a significantly probable condition that poses threat.
   Other	Moderate
   	Undiagnosed new	Differential diagnosis likely to be high risk morbidity if left untreated

   Content of this table include terms and definitions as noted in the 2023 CPT® codebook published by the AMA

3. Identify the Source of Data Ordered, Reviewed, Personally Interpreted, or History Obtained from Another Source
   Due to the many complexities of tax identification numbers, provider contracts, relationships with laboratories, etc., it can be difficult for coders to know for certain who gets credit for the data elements being analyzed. To make this easier, consider the following:
   • Document all data reviewed from a single source (e.g, ABC Hospital reports including lab, discharge summary, ED report).
   • Document data ordered, performed by an external provider, but independently interpreted and document your interpretation in the record (does not have to be a separate report).
   • Document the name of any contributing historians to the patient’s record and any physicians you speak with regarding the patient’s care that are not part of your immediate specialty/team.
   • Point of Care Testing (POCT) (e.g., pregnancy tests, urinalysis, strep test) and lab tests that have a result, that are not modifier 26 eligible or a separately billable global service should be documented clearly.
   
   Because the MDM element of “Data Reviewed and Analyzed” can be a scoring nightmare, consider setting an internal policy to allow coders to base the overall level of MDM from scoring the first element (Problems Addressed) and the third element (Risk of Patient Treatment). Reserve scoring the second MDM data element for circumstances of poor documentation, where either the first or third MDM element have not been documented at all.
   
   
4. Specify the risks of the recommended treatment specific to the patient
   According to the CPT® definition of the third element of MDM - Risk of Complications and/or Morbidity or Mortality of Patient Management, or Risk for short - the level of risk is determined by the treating provider based on the “consequences of the problem(s) addressed at the encounter when appropriately treated.” There are many risks of patient management, such as risk of death with general anesthetic, which is a general risk; however, what should be documented is any specific risks to this patient for the recommended treatments, considering their health status, other chronic conditions, illnesses, and social determinants of health (SDoH). Providers who identify complicating factors, co-morbidities that can impact treatment, or specific risks to the patient with and without treatment, can significantly impact the level of risk selected for an encounter.
   
   
5. Understand How to Calculate and Document Provider Time
   Provider time is calculated as face-to-face and non-face-to-face time spent providing care to the patient on the day of the encounter. Do not include clinical or nursing staff time in the total time documented. Identify the activities that count for non-face-to-face time and be sure to include these accurately in your total time. There is no need to document that “50% or more of the time was spent counseling or coordinating patient care,” and actually this statement may hurt more than be helpful, so consider removing it.

While there are many nuances associated with the new E/M coding guidelines, these five key documentation points will likely have the greatest outcome. Each of these items is readily available to the provider at the time of the encounter, only truly known by the treating provider, and when documented, reduces physician queries and possible down-coding often associated with incomplete documentation or incomplete information.

As you can see, providers play a significant role in scoring E/M services, even when they aren’t actually scoring them. Provider documentation that includes the right details can make all the difference in E/M level selection and preventing revenue losses in the face of an audit. Encourage providers to understand the new guidelines where they have influence and affect change and then review, refine, and readdress as needed. Providers have a vested interest in the success of the organizations they work in, and deserve to know how they can improve coding outcomes for the services they provide.

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