Q&A: History and exam for E/M coding

Q: What role do the history and exam play in determining the level of an evaluation and management (E/M) service? Are they optional?

A: Although the history and examination are not used to select a level of service, the documentation of these components remains vital.

For levels of service selected based on time, the time spent obtaining history and performance of the exam are considered part of the total time.

For services based on medical decision-making, documentation of the patient’s presenting problem or problems, identification of relevant chronic conditions and relevant family, and/or social history help support the overall complexity of the service. These conditions can be contributory and counted when relevant and addressed during the encounter as part of the overall treatment plan. This can especially have an impact on overall level when a provider is managing many chronic conditions when cumulatively they increase the medical decision-making process. Information obtained during a review of systems can also identify relevant symptomatic body systems that may also require addressing during the encounter even if not the reason for the visit.

Medical necessity to support the order and/or review of additional testing, the need to discuss the findings with other providers, or treatment options can be contained in abnormal physical exam findings. Additionally, the definitive diagnoses and/or symptoms for these abnormal conditions or findings can contribute to the identified number of problems addressed during the encounter.

For both history and physical exams, certain conditions can also identify a reason to obtain history from someone other than the patient, such as in cases of severe dementia, communication issues or even for a child where a parent is a more reliable historian.

Medical record documentation provides continuity of care for all providers participating in the care of a patient. This information can help by identifying historical conditions the patient may have had in the past, as well as identify conditions currently being treated. Although the ultimate level of service can either be based on time or medical decisions, these are not the only requirements in the documentation.

There are also some reimbursement methodologies that utilize primarily ICD-10-CM diagnosis code information to determine the cost of covering the patient by the payer versus the reporting of CPT codes on an individual encounter basis. One such methodology is risk adjustment, where capture of all conditions the patient is seen for during a specific time period helps to show a picture of the patient’s overall health status. Clinically supported documentation and relevance to an encounter help determine overall risk of covering the beneficiary.

Editor’s note: This Q&A originally appeared in JustCoding, and comes from HCPro’s Evaluation and Management Boot Camp.