How To Use the Evaluation & Management
(E&M) Codes Properly

Part 1:   The 3 Key Components of the E/M Guidelines

This section was compiled by Frank M. Painter, D.C.
Send all comments or additions to:

FROM:   Chiropractic Economics

By Kathy Mills Chang, MCS-P

   Jump to:
   Part 2:   A Closer Look at E/M Guidelines   or
   Part 3:   Mastering the E/M Guidelines   

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 patientís 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 patientís story ó 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 isnít 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 theyíre 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? Itís 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 theyíve received, there are only two choices for DCs: seriously improve documentation practices or face the possibility of having payments withheld when documentation is absent.

Worse yet, chiropractors could risk having prepayment reviews on all of their claims (an OIG recommendation to CMS). This is similar to how you would discipline your child if he or she came home from school with a big red F on a report card. If the chiropractic profession doesnít turn things around, and start documenting correctly, DCs are going to get a time-out.

Chiropractic is one of the only medical professions that consistently obtains optimal patient results. The continual failing documentation grades do not reflect a profession that does good work. In fact, it is your duty and responsibility to the patient, in addition to the standard of care, to accurately document in the patient record.

Just as a picture tells a visual story, the patientís health record must also tell a documented story. If an auditor were to come to your office today and look at one of your patientís files, would there be a clear picture? Is there an obvious differentiation between your active, medically necessary care and your wellness or maintenance care?

It all begins with solid documentation of your E/M service. Divided into the patientís history, examination, and doctorís clinical decision-making, this service leads the way for you to lay down foundational documentation for this episode of care. Donít forget the auditorís credo: ďIf itís not in the record, then it didnít happen.Ē

In order to correctly select the appropriate level of an E/M service, all patient information must be must be properly documented and meet AMA Current Procedural Terminology (CPT) requirements. So, if selecting the correct levels of the E/M service has you wishing you were back in chiropractic college, fear not. The following will help you be part of the solution in transforming OIG failing grades into golden stars for chiropractic.

First, relax:   Itís not that difficult to document correctly. In fact, itís much easier than making a spinal adjustment. By documenting correctly you can accurately and with confidence choose the correct levels of E/M service to submit to your third-party payers. Itís time to start getting it right ó and be appropriately paid ó for what youíre really worth.

The four elements of the patient history

The chief complaint (CC); history of present illness (HPI); review of systems (ROS); and past, family and/or social history (PFSH) are the four components of patient history as required by the E/M documentation guidelines.

Chief complaint:   The CC is generally the patientís stated reason for the encounter. According to Mosbyís Dictionary, the CC is ďa subjective statement made by a patient describing the most significant symptoms or signs of illness or dysfunction that caused him or her to seek health care.Ē

History of present illness:   The HPI is a chronological description of the development of the patientís present illness from the first sign or symptom or from the previous encounter to the present. The HPI includes location, quality, severity, duration, timing, context, modifying factors, and eClaims

Associated signs and symptoms.

For example:   John Doe presents complaining of sharp, stabbing pains in his neck that radiate down into his left shoulder. The pain severity is 6/10. He has been suffering with this pain for five days and it is generally worse in the mornings when he rises. After he has coffee and a hot shower, the pain seems to subside but recurs when he works at his computer. Since the pain started he has noticed some numbness and tingling in the last three digits of his left hand.


  * Location: neck and left shoulder
  * Quality of the symptom: sharp, stabbing
  * Severity: 6/10
  * Duration: 5 days
  * Timing (when it occurs): in the morning
  * Context of onset: when he rises
  * Modifying factors: hot shower alleviates pain; computer work aggravates pain
  * Associated signs/symptoms: numbness in fingers of left hand

Tip 1:   Only the provider may obtain and document the HPI. This is also where you want to start counting as the eight elements of HPI will often determine the level of history you are able to report.

Review of symptoms:   The ROS is a system-by-system review of body functions that begins during the initial patient interview and is completed during the physical exam. According to Huffmanís Health Information Management, ďthe ROS is an inventory of symptoms to reveal subjective symptoms that the patient either forgot to describe or which at the time seemed relatively unimportant. In general, an analysis of the subjective findings will indicate the nature and extent of the examination required.Ē [1] The ROS is usually a list of questions grouped by organ systems that should be part of your patient intake forms, and cover all of the following:


  * Constitutional
  * Eyes
  * Ears, nose, mouth and throat
  * Cardiovascular
  * Respiratory
  * Gastrointestinal
  * Genitourinary
  * Musculoskeletal
  * Integumentary
  * Neurologic
  * Psychiatric
  * Endocrine
  * Hematologic/lymphatic
  * Allergic/immunologic

Past, family, and/or social history: PFSH has three components:

Past history is the patientís previous experience with illnesses, injuries, hospitalizations, surgeries, treatments, allergies, age appropriate immunizations, diet restrictions, and current medications. Family history is the review of the patientís family members and includes important information about the health status or cause of death of parents, siblings, and children; any specific diseases that would relate to the problem of the patientís CC, HPI, or ROS; and any hereditary diseases that might place the patient at risk. Social history covers the patientís past and current information relating to marital status/living arrangements; current employment; occupational history; use of drugs, alcohol, or tobacco; level of education; and sexual history.

Tip 2:   The patient and ancillary staff may record and document ROS and PHSH. The provider must review and sign both the ROS and PHSH to indicate he or she has evaluated the information. Make sure your intake paperwork does most of the heavy lifting for you and that a team member has reviewed it for completeness.

Tip 3:   For re-exams ó whenever a doctor chooses to refer to an ROS or PFSH for a re-exam ó it must be referenced by date (e.g., ďROS and PFSH were reviewed from February 24, 2011; no changes or change was noted at ...Ē)

Determining the correct level of history

The health history you take from the patient is the first key component required in selecting the appropriate level of the E/M service. Once you have obtained information from the four elements of the patientís history ó CC, HPI, ROS, and PFSH, the next step is assigning the correct level of history:

  * Problem focused
  * Expanded focus
  * Detailed
  * Comprehensive

Reference the following chart to select the history level based on the four elements of CC, HPI, ROS, and PFSH

HPI ROS PFSH Level of history
Brief N/A N/A Problem focused
Brief Problem focused N/A Expanded focus
Extended Extended Pertinent Detailed
Extended Complete Complete Comprehensive

Obtaining and documenting as much information from the patient history as possible is a very important aspect of the patientís evaluation; it will also allow you to bill a higher level of E/M service. Making sure you have met and documented all the E/M requirements before selecting the code is the first step toward improving your documentation. The next two parts of this series will cover examination and clinical decision-making. Get ready to raise your game.

Kathy Mills Chang is the founder of her own consulting firm assisting doctors with finding financial and reimbursement ease in practice. She also serves as Foot Levelersí insurance adviser and can be reached at 888-659-8777 or


1.     Huffman EK. Health Information Management. 10th ed. Berwyn, Ill: Physiciansí Record Company; 1994.



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