Get it in Writing!

The E/M guidelines are ambiguous on several key points of documentation. There are several gray areas which may affect how your documentation is audited by your particular Medicare carrier. We recommend that you cut and paste the questions below into an email and send them to your carrier. When you get a reply, please forward a copy to Dr. Jensen at pjensen@emuniversity.com so we can post the answers on our site.

1. The 1997 E/M guidelines allow you to complete an EXTENDED HPI by commenting on the status of three or more “chronic or inactive problems." Can we also use this rule when completing the HPI using the 1995 E/M guidelines (Or do we have to use FOUR comorbidities as outlined in the official 1995 rules)? Also, no mention is made of using "chronic or inactive problems" to complete a BRIEF HPI. Is it correct to assume that if you comment on one to two problems that you can qualify for a BRIEF HPI. Can we use this for both the 1997 and the 1995 E/M guidlines? Finally, what is meant by "chronic or inactive problems." If we are writing a progress note for a patient in the hospital, can we use the problems we are addressing from day to day to care for the patient--even though they are technically neither "chronic" nor "inactive?"
2. If I document the most pertinent systems under the ROS, is it okay to say, "All other systems reviewed and are negative?"
3. Is it okay for me to refer to an earlier note's PFSH and ROS when I see the patient in the office?  If so, what do I have to document?
4. What is required for a comprehensive physical exam using the 1995 E/M guidelines?  Do you have to have eight or more organ systems or can you use the body areas?
5. How do your auditors tell the difference between and EPF exam and a detailed exam using the 1995 E/M guidelines?
6. When using the 1995 guidelines for the physical exam, can I say “unremarkable” if an organ system has normal findings?
7. Can I say “non-contributory” when completing the FH if the information obtained is not germane to the clinical problems at hand?
8. What exactly is meant by prescription drug management in the table of risk?  Do I have to add, stop or adjust a drug?
9. Can I use a questionnaire when completing the ROS and PFSH and if so, what documentation is required?
10. Do your auditors use a point system to quantify the MDM and, if so, can you provide me with the rules and your auditing form so I can incorporate the rules correctly into my compliance plan?