Evaluation and Management Physician Encounter Doumentation Requirements

Updated: Jun 17

Medicare Documentation Requirements: 

E & M Services Documentation

By Angela Breslin BSN, R.N

Simply stated, Medicare documentation for Evaluation & Management Physician Encounters is the key to a quality driven, results achieving, compliant and successful business. Most Medicare Evaluation & Management Physician Encounter claims that are denied are denied due to issues related to Medicare documentation errors.

Medicare states that the Medicare documentation, “should be of such content and clarity as to make it abundantly clear to any third-party reviewer, the patient’s symptoms, history, physical findings, and plan of treatment…or the claim will be denied as not be medically necessary.”

Additionally, at a high level, Medicare documentation should meet all of the following expectations:

  1. All Medicare documentation should be complete, legible, signed and dated

  2. Medicare documentation is the recording of pertinent facts and observations about an individual’s health history, including past and present illness, test results, treatment and outcomes.

  3. The Medicare documentation of each patient encounter should include: the date, the reason for the encounter, appropriate history and physical exam, review of lab results, x-ray results, other ancillary services (where appropriate) assessment, and plan of treatment

  4. If your billing codes are time based, then the Medicare documentation must clearly and accurately notate how much time was spent with the Medicare beneficiary.

  5. If your billing for E/M services, you need to be sure that your Medicare documentation includes History of Present illness (HPI), Review of Symptoms (ROS), and Past Medical, Family, and Social History (PFSH)

  6. Your Medicare documentation should clearly and accurately include the proper ICD-10’s that are required for treatment, testing, and payment

  7. Your modifiers, if appropriate, should reflect what story the Medicare documentation tells

Evaluation & Management Documentation Requirements for Established Patient Encounters by CPT Code:

A few important notes to remember regarding eval & management services:

1. History of Present Illness (HPI) consists of: 

a. Patient’s stated reason for the visit

b. Location

c. Context

d. Duration

e. Quality

f. Modifying factors

g. Severity

h. Timing

i. Associated Signs and symptoms

j. Chronic Situations

2. HPI must be documented by provider

3. Review of Systems (ROS) 

a. Can be obtained in a separate patient intake form

b. Positive and negative responses to symptoms and signs

c. Should be medically necessary

d. Does not need to be completed by physician, but must be reviewed

e. Can utilize 1995 or 1997 documentation guideline

4. Medical Decision Making (MDM)

a. Includes diagnosis/problems, data reviewed, risk of complications, morbidity, mortality and overall risk

5. Tips for documenting MDM

a. Record relevant impressions, diagnoses, therapeutic options chosen to every stated problem

b. Document all tests ordered, reviewed and visualize each problem individually as part of the work covered by the encounter

c. Summarize old records, consults with other HCP’s, and anything utilized in decision-making

About the author:

Angela M. Breslin is a Registered Nurse (BSN, RN) with some 20 years of clinical experience in a hospital setting. Angela is an expert in Medicare, Medicare, Medicaid, third party payor audits response services, appeals submissions, Medicare audits, and medical LCD compliance.  Angela has effectively responded to and won audit response and payer appeals across many product s and services, including but not limited to, urological supplies, wound care and surgical supplies, ostomy supplies, diabetes testing supplies, CGM, insulin pump therapy, diabetic shoes,  psychiatry, orthoses, breast pump supplies, and emergency services.

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1995 and 1997 Medical Documentation Guidelines

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