Clinical Documentation

Reference Guide
A comprehensive resource for clinical
documentation experts

SECOND EDITION

Clinical Documentation Reference Guide Cover.indd 1 20/05/21 7:14 PM

Clinical Documentation
Reference Guide
A comprehensive resource for clinical documentation experts

SECOND EDITION
 Disclaimer
Decisions should not be made based solely upon information within this reference guide. All judgments impacting career
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Medicare Disclaimer
This publication provides situational examples and explanations, of which many are taken from the Medicare perspective.
The individual, however, should understand that while private payers typically take their lead regarding reimbursement
rates from Medicare, it is not the only set of rules to follow.

While federal and private payers have different objectives (such as the age of the population covered) and use different
contracting practices (such as fee schedules and coverage policies), the plans and providers set similar elements of the
quality in common for all patients. Nevertheless, it is important to consult with individual private payers if you have ques-
tions regarding coverage.

AMA Disclaimer
CPT® copyright 2020 American Medical Association. All rights reserved.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not
part of CPT®, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or
dispense medical services. The AMA assumes no liability for data contained or not contained herein.

CPT® is a registered trademark of the American Medical Association.

The responsibility for the content of any “National Correct Coding Policy” included in this product is with the Centers for
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responsibility for any consequences or liability attributable to or related to any use, nonuse or interpretation of information
contained in this product.

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ii Clinical Documentation Reference Guide AAPC | 1-800-626-2633

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

Chapter 1
The Purpose of Clinical Documentation Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
The Quality of Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
The Least Expected . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Financial Impact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Legal Protection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Routine Checks for Quality Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Mastering the Documentation Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Frequently Asked Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Chapter 2
Implementation of a CDI Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Conduct Appropriate Training and Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Enforcement of Protocols . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Frequently Asked Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Chapter 3
Evaluation and Management Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
An Overview of the Anatomy of the Documentation Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
1995 and 1997 Documentation Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Frequently Asked Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Chapter 4
2021 Office or Other Outpatient Services Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
American Medical Association’s (AMA’s) 2021 Office/Outpatient E/M Codes: New Patient . . . . . . . . . . . . . . . . . . . . . . 33
AMA 2021 Office/Outpatient E/M Codes: Established Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
2021 AMA CPT® E/M Guidelines Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Time and Separate Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Office/Outpatient History and Exam . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
Medical Decision Making . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
2021 Level of Medical Decision Making (MDM) Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Frequently Asked Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

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 Chapter 5
Procedural Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Global Surgery Package . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Medicare Surgical Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Global Surgery Status Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Frequently Asked Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Monitor Op Reports for Accuracy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

Chapter 6
Medical Necessity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Medical Necessity and CMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Recovery Audit Contractors (RAC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
RAC Audit Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
CERT & RAC Common Documentation Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Frequently Asked Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Chapter 7
Clinical Conditions and Diagnosis Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Use Both Alphabetic Index and Tabular List . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Level of Detail in Coding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Excel With Auditing Advice for ICD-10-CM and CDI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
How to Prepare for an Audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Post-Audit Provider Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Frequently Asked Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

Chapter 8
Incident-to Guidelines and Shared Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Incident-to Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Split/Shared Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Split/Shared Services vs. Incident-to Billing Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

Chapter 9
Electronic Medical Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Templates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Fast Facts About EMR Templates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Templates are NOT one-size-fits-all . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
EMR Templates: A Boon or a Bane? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Copy and Paste . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

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 Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Ace EMR Documentation With These Guidelines and Tips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Concision Is Key: Document Efficiently . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Keep a Separate Section for the CC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Don’t Just Correct – Perfect – Your EMR Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
10 Tips for Keeping EMR Compliance Issues at Bay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Outsmart the Auto-Populate Feature in EMRs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Guard Against These Top EMR Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Frequently Asked Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

Chapter 10
Communication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Clinical Documentation Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
1.   Centers for Medicare & Medicaid Services. 1995 Documentation Guidelines for
Evaluation and Management Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
2.   Centers for Medicare & Medicaid Services. 1997 Documentation Guidelines for
Evaluation and Management Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
3.   Fact Sheet - Physician Fee Schedule (PFS) Payment for Office/Outpatient
Evaluation and Management (E/M) Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
4.   Centers for Medicare & Medicaid Services. Electronic Health Records Provider. . . . . . . . . . . . . . . . . . . . . . . 157
5.   Centers for Medicare & Medicaid Services, MLN Booklet Evaluation and
Management Services Guide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
6.   Centers for Medicare & Medicaid Services. National Physician Fee Schedule Relative Value Files. . . . . . . . 186
7.   Department of Health and Human Services, Office of Inspector General, OIG Compliance Program for
Individual and Small Group Physician Practices. Oct. 5, 2000, Federal Register, Vol. 65, No. 194. . . . . . . . 200
8.   Medicare Benefit Policy Manual, MCM, 60 - Services and Supplies Furnished
Incident-To a Physician’s/NPP’s Professional Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 219

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 Introduction

Designed for all clinical documentation improvement (CDI) team members, this
NOTES
book will help you and your team better understand the role documentation plays
in care management, coding, and billing. Proper documentation ensures quality
patient care and optimal reimbursement through more accurate coding and
compliance. Accurate documentation is also your one best defense in the event of
litigation. The Clinical Documentation Reference Guide walks you through the
minefield of common documentation pitfalls and teaches you the skills necessary
to create, overhaul, or enhance your organization’s documentation improvement
program to protect your reimbursement and operate ethically.

This extensive guide is filled with page after page of insights to guide you in devel-
oping or expanding the qualities necessary to meet and manage clinical documen-
tation. This start-to-finish CDI primer covers medical necessity, joint/shared visits,
incident-to billing, preventative care visits, the global surgical package, complica-
tions and comorbidities, and CDI for EMRs.

Prevent documentation deficiencies and keep your claims on track for optimal
reimbursement with this expert guidance:
l Understand the legal aspects of documentation.

l Anticipate and avoid documentation trouble spots.

l Keep compliance issues at bay.

l Learn proactive measures to eliminate documentation problems.

l Work the coding mantra — specificity, specificity, specificity.

l Avoid common documentation errors identified by CERT and RACs.

l Know the facts about EMR templates — and the pitfalls of auto-populate
features.
l Master documentation in the EMR with guidelines and tips.

l Conquer CDI for time-based coding for E/M.

Learn the all-important steps to ensure your records capture the work your
providers perform during each encounter. Benefit from methods to effectively
communicate CDI concerns and protocols to your providers. Leverage the prac-
tical and effective guidance in the Clinical Documentation Reference Guide to
triumph over your toughest documentation challenges.

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Evaluation and Management Documentation Chapter 3

a documented CC which, if not documented as a separate statement, may be pulled

NOTES
from the HPI.

Tip: If the CC has not been documented, the visit is not billable.

The HPI is a description of the patient’s current problem or illness. Table 3.1 charts
out the eight different elements of HPI:

Element Examples of Documentation

Location Eye pain, shoulder pain
Quality Yellow-thick sputum
Severity Pain scale 5 out of 10
Duration For the past three weeks
Timing This morning, yesterday
Context Fell while riding bike
Modifying factors Patient took pain meds
Associated signs and symptoms Also, complains of itchy-watery eyes

Table 3.1: HPI Elements and Examples

The 1997 guidelines allow the provider the option of documenting four or more
elements from the HPI, or the status of three chronic conditions for an extended
HPI. CMS also allows an extended HPI for the status of three chronic conditions in
the 1995 guidelines as well.

The ROS is a review of the 14 body systems. Table 3.2 shows a list of the body
systems with examples.

Body Systems Examples of Documentation

Constitutional Weight loss, weakness, fever
Eyes Itching, blurred vision
Ears, nose, and throat Congestion, sore throat
Cardiovascular Chest pain, flutter, fibrillation
Respiratory Shortness of breath, cough
Gastrointestinal Diarrhea, vomiting
Genitourinary Dark urine, burning on urination
Musculoskeletal Muscle pain and weakness, joint swelling
Integumentary Rash, acne
Neurological Syncope, tingling
Psychiatric Stress, anxiety, depression
Endocrine Increase in thirst, decreased appetite
Hematologic/Lymphatic Bruising, swollen glands
Allergy/Immune Medication allergies, itching, anaphylaxis

Table 3.2: Review of Body Systems and Examples

During the ROS, the provider asks the patient if they are experiencing any signs or
symptoms in any of the body systems. Ancillary staff, physician assistants, nurse
practitioners, and physicians can document the ROS.

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 CHAPTER 5 Procedural Documentation

An operative report is a note produced by a healthcare professional for proce-

NOTES
dures they provide. The report must be written or dictated immediately after the
procedure was performed and must contain a detailed summary of the findings
throughout the surgery, the procedure performed, any specimens removed, the
pre- and postoperative diagnoses, and the names of the primary performing
surgeon and any assistants.

An operative report is typically divided into four main sections that include
the header, indications for surgery, the detail or body of the procedure, and the
findings.

The header of an operative note is designed to identify:

l Patient name

l Date of surgery

l Preoperative diagnosis

l Postoperative diagnosis

l The procedure performed

l Primary surgeon

l Assistant surgeon(s)

l Anesthesia administered

l Anesthesiologist

The indication typically gives a brief history outlining the reasons for medical
necessity for the procedure. Specific details of the surgery are described in the
body of the note. The details in this area will determine the CPT® code(s) used
to convey the surgical services performed. This description usually begins with
the documentation of healthcare staff taking a “time out” to verify they have the
correct patient, and identification of the expected procedure to take place. After
this verification has been made, the operative note will provide details of the entire
surgery, beginning with prepping the patient and the approach, and continuing
to explain any findings, removal of specimens for analysis, and/or intra-operative
complications.

The operative report will be finalized with the findings upon completion of the
surgery. Estimated blood loss will be documented here, as well as the status of the
patient upon completion of the surgery.

Reading and analyzing an operative report requires time and great attention to
detail. Challenges arise when the report indicates a specific procedure as being
performed in the header, but the details in the body of the note do not support
that procedure, or indicate additional procedures not reported in the title. For this
reason, it is very important to read the entire note slowly and carefully. Attempt to
gain an understanding of the entire surgical case before taking more time to read
the report thoroughly to analyze for proper code assignment.

Remember that physicians write an operative note in a manner that would be

easily understood and interpreted by their colleagues. If there are elements missing

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Electronic Medical Records Chapter 9

form should be adjustable for each patient and should not create an exact duplicate
NOTES
record across several patients who all came in with the same key complaints.

All patients are unique in their treatment needs, and their records should be, too.
A single template cannot adequately capture the care of all patients, and practices
will need to adjust these forms on a regular basis based on practice and patient
requirements.

Caution: Most payers and auditors are not in favor of templates and may often
report their use in an audit report and scores.

Tip: CDI team members should note certain nuances or suggested changes to the
template and discuss these revisions with the CDS or practice manager. Updates
can be added as and when needed, based on the specific considerations of the
patients of that practice.

EMR Templates: A Boon or a Bane?

Downside: As speedy and convenient as they are to operate, templates create their
own set of problems. Attorneys are increasingly reporting that EMR systems are
keeping them in business, and it’s the templates, across the board, that are the
biggest culprit.

Physicians must fully document within the EMR using their own words, rather
than letting the computer fill it out or auto-populate the record for them. Keep
in mind, when providers dictated their notes, they had to carefully consider each
patient encounter to provide enough detail for the transcriptionist. Now, the
computer does the work for them. Even though the result looks similar, computers
cannot match the scope of the clinician’s thought process 100 percent.

Hidden trap: Since the implementation of EMR systems, there has been an
increase in concerns about documentation across providers and payers. The
computerization of information in the medical record means a whole new set of
errors that are foreign to handwritten paper documentation and dictated notes.

These unique types of errors have warranted greater exposure and increased scru-
tiny of claims, with the added risk to physicians of being accused of professional
malpractice. And EMR systems are, of course, on the radar of CMS and the OIG.

Caution: Watch out for the self-populating fields, or “exploding” documenta-

tion feature, which add in all of the patient’s prior clinical history at the click of
a checkbox. These fields may seem like a time-saving function, but incorrectly
completing them can do great harm to a provider and, ultimately, the patients.

Mistake: Depending on which EMR the physician uses, they may inadvertently
document a full assessment and ROS that they have yet to perform (or may not
perform at all). If the physician does not take the time to review the documenta-
tion, the coder will code the services, which will then be billed to the payer, leading
to incorrect reimbursement and a possible fraud investigation. Compounding
this problem is the fact that documentation for subsequent encounters will also be
impacted by the incorrect documentation.

Copy and Paste

Physicians and staff should use extreme caution when using the copy and paste
function if available within software templates. Copying information from one

74 Clinical Documentation Reference Guide AAPC | 1-800-626-2633

 CHAPTER 10 Communication

A physician query is a method of communication used by coders and clinical

NOTES
documentation professionals to request clarification of patient diagnoses or proce-
dures from the physician. The physician query is used to clarify documentation
by resolving conflicting, ambiguous, illegible, or incomplete information about
significant conditions, procedures, or reasons for tests in the medical record of the
patient. Queries may also be required to determine the correct code for a primary
diagnosis or procedure, or to clarify if a causal relationship exists between two
diagnoses. In addition to obtaining clarification, the query may serve as an educa-
tional tool to improve physician documentation and the coders’ understanding of
clinical scenarios.

Queries can be done while the patient is still admitted to the hospital or prior to
leaving the physician’s office. This allows the physician an opportunity to clarify
a diagnosis or procedure prior to the patient’s departure. These are called concur-
rent reviews and queries. A query conducted after the patient has left is called a
retrospective query. In the outpatient setting, review of the patient’s medical record
prior to admission can provide opportunities to query at the encounter. This is
often called prospective documentation review. The facilities’ processes should
include some manner of recording the queries, such as an electronic database, or
inclusion of the query in the medical record.

The query should include:

l Patient name

l Admission date and/or date of service

l Health record number

l Account number

l Date query initiated

l Name and contact information of the individual initiating the query

l Statement of the issue in the form of a question along with clinical indicators
specified from the chart

The query should not be constructed in a manner that can be interpreted as

leading the physician. Queries can be verbal, open, multiple choice, or yes/no, and
should provide documentation from the medical record to obtain a more concise
diagnosis from the physician. When multiple choice or yes/no queries are utilized
it is important to provide choices for a physician including options like “other” or
“unspecified.” Unlike querying in the inpatient setting, outpatient queries should
not include terms like “probable,” “suspected,” “ruled out,” etc. These options do
not apply as per outpatient coding guidelines only confirmed diagnoses can be
coded.

A valuable skill and necessary tool for a documentation specialist is learning how
and when it is appropriate to query a physician. Querying assists with accurate
diagnostic, procedural, and risk adjustment coding. During concurrent coding,
querying for clarification can help to determine if a patient has additional proce-
dures or complications that may affect discharge management. Particularly in the
outpatient setting, conducting a prospective review and initiating relevant queries

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Clinical Documentation Resources

children, adolescents and pregnant women may have additional or modified

information recorded in each history and examination area.

As an example, newborn records may include under history of the present illness
(HPI) the details of mother's pregnancy and the infant's status at birth; social
history will focus on family structure; family history will focus on congenital
anomalies and hereditary disorders in the family. In addition, the content of a
pediatric examination will vary with the age and development of the child.
Although not specifically defined in these documentation guidelines, these
patient group variations on history and examination are appropriate.

A. DOCUMENTATION OF HISTORY

The levels of E/M services are based on four levels of history (Problem Focused,
Expanded Problem Focused, Detailed, and Comprehensive). Each type of history
includes some or all of the following elements:

Chief complaint (CC)

History of present illness (HPI)

Review of systems (ROS) and

Past, family, and/or social history (PFSH).

The extent of the history of present illness, review of systems, and past, family
and/or social history that is obtained and documented is dependent upon clinical
judgment and the nature of the presenting problem(s).

The chart below shows the progression of the elements required for each type of
history. To qualify for a given type of history all three elements in the table must
be met. (A chief complaint is indicated at all levels.)

History of Present Review of Systems Past, Family, and/or Type of History

Illness (HPI) (ROS) Social History (PFSH)
Brief N/A N/A Problem Focused
Focused Expanded
Brief Problem Problem Pertinent N/A
Problem
Extended Extended Pertinent Detailed
Extended Complete Complete Comprehensive

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 Clinical Documentation Resources

5.   Centers for Medicare & Medicaid Services, MLN Booklet Evaluation and Management
Services Guide.
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-
guide-ICN006764.pdf

PRINT-FRIENDLY VERSION

BOOKLET

EVALUATION AND MANAGEMENT SERVICES GUIDE

UPDATES

• Updated for 2021 Medicare Physician Fee Schedule final rule dates and links

CPT only copyright 2020 American Medical Association. All rights reserved. CPT is a registered trademark
of the American Medical Association. Applicable FARS/HHSAR Restrictions Apply to Government Use. Fee
schedules, relative value units, conversion factors, and/or related components are not assigned by the AMA,
are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly
practice medicine or dispense medical services. The AMA assumes no liability for data contained or not
contained herein.

Page 1 of 23 MLN906764 February 2021

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Clinical Documentation Resources

Evaluation and Management Services Guide MLN Booklet

Single Organ System Examination

TYPE OF EXAMINATION DESCRIPTION
Include performance and documentation of one to
Problem Focused five elements identified by a bullet, whether in a box
with a shaded or unshaded border.
Include performance and documentation of at least
Expanded Problem Focused six elements identified by a bullet, whether in a box
with a shaded or unshaded border.
Examinations other than the eye and psychiatric
examinations should include performance and
documentation of at least twelve elements identified
by a bullet, whether in a box with a shaded or
unshaded border.
Detailed
Eye and psychiatric examinations include the
performance and documentation of at least nine
elements identified by a bullet, whether in a box with
a shaded or unshaded border.
Include performance of all elements identified by a
bullet, whether in a shaded or unshaded box.
Comprehensive
Documentation of every element in each box with a
shaded border and at least one element in a box with
an unshaded border is expected.
Table 3: Single Organ System Examination

Both types of examinations may be performed by any physician, regardless of specialty.

Here are some important points to keep in mind when documenting general multi-system and single organ
system examinations (in both the 1995 and the 1997 documentation guidelines):
● Document specific abnormal and relevant negative findings of the examination of the affected or
symptomatic body area(s) or organ system(s). A notation of “abnormal” without elaboration is
not sufficient.
● Describe abnormal or unexpected findings of the examination of any asymptomatic body area(s) or
organ system(s).
● It is sufficient to provide a brief statement or notation indicating “negative” or “normal” to document
normal findings related to unaffected area(s) or asymptomatic organ system(s).

Page 14 of 23 MLN906764 February 2021

176 Clinical Documentation Reference Guide AAPC | 1-800-626-2633

 Clinical Documentation Resources

Federal Register / Vol. 65, No. 194 / Thursday, October 5, 2000 / Notices 59437

to augment the practice’s own program. The steps outlined below Billing Compliance Program Guidance,
compliance efforts. articulate all seven components of a the OIG recommended that a baseline,
The opportunities for collaborative compliance program and there are or ‘‘snapshot,’’ be used to enable a
compliance efforts could include numerous suggestions for practice to judge over time its progress
participating in training and education implementation within each in reducing or eliminating potential
programs or using another entity’s component. Physician practices should areas of vulnerability. This practice,
policies and procedures as a template keep in mind, as stated earlier, that it is known as ‘‘benchmarking,’’ allows a
from which the physician practice up to the practice to determine the practice to chart its compliance efforts
creates its own version. The OIG manner in which and the extent to by showing a reduction or increase in
encourages this type of collaborative which the practice chooses to the number of claims paid and denied.
effort, where the content is appropriate implement these voluntary measures. The practice’s self-audits can be used
to the setting involved (i.e., the training to determine whether:
is relevant to physician practices as well Step One: Auditing and Monitoring
• Bills are accurately coded and
as the sponsoring provider), because it An ongoing evaluation process is accurately reflect the services provided
provides a means to promote the desired important to a successful compliance (as documented in the medical records);
objective without imposing excessive program. This ongoing evaluation • Documentation is being completed
burdens on the practice or requiring includes not only whether the physician correctly;
physicians to undertake duplicative practice’s standards and procedures are • Services or items provided are
action. However, to prevent possible in fact current and accurate, but also reasonable and necessary; and
anti-kickback or self-referral issues, the whether the compliance program is • Any incentives for unnecessary
OIG recommends that physicians working, i.e., whether individuals are services exist.
consider limiting their participation in a properly carrying out their A baseline audit examines the claim
sponsoring provider’s compliance responsibilities and claims are development and submission process,
program to the areas of training and submitted appropriately. Therefore, an from patient intake through claim
education or policies and procedures. audit is an excellent way for a physician submission and payment, and identifies
The key to avoiding possible conflicts practice to ascertain what, if any, elements within this process that may
is to ensure that the entity providing problem areas exist and focus on the contribute to non-compliance or that
compliance services to a physician risk areas that are associated with those may need to be the focus for improving
practice (its referral source) is not problems. There are two types of execution.7 This audit will establish a
perceived as nor is it operating the reviews that can be performed as part of consistent methodology for selecting
practice compliance program at no this evaluation: (1) A standards and and examining records, and this
charge. For example, if the sponsoring procedures review; and (2) a claims methodology will then serve as a basis
entity conducted claims review for the submission audit. for future audits.
physician practice as part of a There are many ways to conduct a
compliance program or provided 1. Standards and Procedures
baseline audit. The OIG recommends
compliance oversight without charging It is recommended that an that claims/services that were submitted
the practice fair market value for those individual(s) in the physician practice and paid during the initial three months
services, the anti-kickback and Stark be charged with the responsibility of after implementation of the education
self-referral laws would be implicated. periodically reviewing the practice’s and training program be examined, so as
The payment of fair market value by standards and procedures to determine to give the physician practice a
referral sources for compliance services if they are current and complete. If the benchmark against which to measure
will generally address these concerns. standards and procedures are found to future compliance effectiveness.
be ineffective or outdated, they should Following the baseline audit, a
B. Steps for Implementing a Voluntary be updated to reflect changes in
Compliance Program general recommendation is that periodic
Government regulations or audits be conducted at least once each
As previously discussed, compendiums generally relied upon by year to ensure that the compliance
implementing a voluntary compliance physicians and insurers (i.e., changes in program is being followed. Optimally, a
program can be a multi-tiered process. Current Procedural Terminology (CPT) randomly selected number of medical
Initial development of the compliance and ICD–9–CM codes). records could be reviewed to ensure that
program can be focused on practice risk the coding was performed accurately.
areas that have been problematic for the 2. Claims Submission Audit
Although there is no set formula to how
practice such as coding and billing. In addition to the standards and
many medical records should be
Within this area, the practice should procedures themselves, it is advisable
reviewed, a basic guide is five or more
examine its claims denial history or that bills and medical records be
medical records per Federal payor (i.e.,
claims that have resulted in repeated reviewed for compliance with
Medicare, Medicaid), or five to ten
overpayments, and identify and correct applicable coding, billing and
medical records per physician. The OIG
the most frequent sources of those documentation requirements. The
realizes that physician practices receive
denials or overpayments. A review of individuals from the physician practice
reimbursement from a number of
claim denials will help the practice involved in these self-audits would
different payors, and we would
scrutinize a significant risk area and ideally include the person in charge of
encourage a physician practice’s
improve its cash flow by submitting billing (if the practice has such a
auditing/monitoring process to consist
correct claims that will be paid the first person) and a medically trained person
of a review of claims from all Federal
time they are submitted. As this (e.g., registered nurse or preferably a
payors from which the practice receives
example illustrates, a compliance physician (physicians can rotate in this
reimbursement. Of course, the larger the
program for a physician practice often position)). Each physician practice
sample size, the larger the comfort level
makes sound business sense. needs to decide for itself whether to
The following is a suggested order of review claims retrospectively or 7 See Appendix D.II. referencing the Provider
the steps a practice could take to begin concurrently with the claims Self-Disclosure Protocol for information on how to
the development of a compliance submission. In the Third-Party Medical conduct a baseline audit.

VerDate 11<MAY>2000 15:34 Oct 04, 2000 Jkt 194001 PO 00000 Frm 00048 Fmt 4703 Sfmt 4703 E:\FR\FM\05OCN1.SGM pfrm02 PsN: 05OCN1
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