How To Use the Evaluation & Management (E&M) Codes Properly:
Part I: The 3 Key Components of the E/M Guidelines
SOURCE: Chiropractic Economics
By Kathy Mills Chang, MCS-P
Part I: The 3 Key Components of
the Evaluation & Management
In order to document your history, diagnosis, and treatment of patients in accord with rules set out by the Centers for Medicare and Medicaid Services (CMS) and the Office of Inspector General (OIG), your patient record should address: (1) Patient history, (2) Examination, and (3) Medical decision-making (MDM). These three components are addressed in the following three articles, which also make reference to the Sample Worksheet included with Part III
As regulatory and insurance guidelines tighten, the quality of your evaluation and management documentation is more important than ever before.
Just like a great story, the patient’s notes for an episode of care must have a beginning, middle, and end. This article is a review of the first of three parts of evaluation and management (E/M) documentation, and its focus is on the beginning of the patient’s story — the history. More information on the next two key E/M components will be presented in future issues of this magazine.
Three key components of the E/M guidelines:
* One: Patient history
* Two: Examination
* Three: MDM (medical decision-making)
You are probably aware of the error rates released by the Office of Inspector General (OIG). It seems that over the years chiropractors have consistently scored low when it comes to patient documentation. According to the 2009 OIG report, 83 percent of all chiropractic claims submitted failed to meet documentation requirements.
Certainly chiropractic isn’t the only specialty in the healthcare industry that struggles with documenting correctly. However, according to the OIG, chiropractors are the ones who seem to be having the most problems with improvement.
Some members of the profession have tuned out discussions about documentation, thinking they’re being targeted by the Centers for Medicare and Medicaid Services (CMS) and the OIG. After all, who can actually breathe the rarified air of perfect documentation? It’s time for chiropractors to start getting it right if they ever want to get off the lowest rung of the ladder, and elevate their ever-dwindling reimbursement rates.
Faced with the failing grades they’ve received, there are only two choices for DCs: seriously improve documentation practices or face the possibility of having payments withheld when documentation is absent.