Evaluation and Management Documentation Requirements – CMS vs. CPT

FAQ 1. Should I use CMS (Center for Medicare and Medicaid Services) or CPT (AMA’s Current Procedural Terminology) Evaluation and Management (E/M) guidelines when coding?

When coding for a claim that will be submitted to Medicare, you must use CMS' Medicare Documentation Guidelines for Evaluation and Management services. Some groups choose to follow CMS’ guidelines across the board for all payers. Others follow CMS guidelines for Medicare and other governmental payers and apply CPT rules for all other patients. Keep in mind that for other payers, which guidelines you use will most likely depend upon whether or not you participate with the payer. If you participate, you must use the payer's designated guidelines and comply with associated payer policies. If you do not participate with a payer, then usually the CPT guidelines pertain.

 
FAQ 2.  I understand there are differences between CMS and CPT E/M guidelines. How do these differences affect Emergency Medicine Coding?

CPT rules are generally less numerically concrete and allow some latitude based on the medical necessity of the particular clinical encounter. CMS uses CPT service criteria as a foundation, but also makes additions and deletions.  CMS is obligated to formally notify providers of its modifications to CPT requirements; in the absence of such specific notifications CPT requirements are understood to be in effect for Medicare patients. For E/M codes, CMS instructs their contractors to audit charts by either CMS’ 1995 guidelines or its 1997 guidelines, whichever most benefits the physician. The vast majority of emergency medicine groups use CMS’ 1995 guidelines over the 1997 guidelines. Consequently this FAQ will focus on the 1995 guidelines for CMS discussions.

The 1995 CMS guidelines were issued as a collaborative effort between the AMA and HCFA (now CMS) to help physicians understand the CMS guidelines in context with the AMA's Current Procedural Terminology (CPT) coding system. 

The Marshfield Clinic audit tool and other CMS contractor adaptations have further refined the application of guidelines to include numerical sub-element requirements.  Medicare publishes an Evaluation and Management Guide which is distributed by most MACs, available on the CMS website and can help providers clarify the more subjective components of E/M levels.  https://www.cms.gov/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf

 
FAQ 3. What are the components for Emergency Department E/M services?

There are seven components contained within Evaluation and Management (E/M) service guidelines: history, exam, medical decision making, counseling, coordination of care, nature of presenting problem, and time. The first three are considered the key components used in selecting the appropriate E/M service code.

 
FAQ 4.  How are the History components defined?

The CMS and CPT history components are the same.

History documentation includes the history of present illness (HPI), review of systems (ROS) and past medical, family, and social history (PMFSH). These elements may be documented separately or contained within one statement. The E/M guidelines recognize four levels, and all require a chief complaint:

Problem Focused: Brief history of present illness or problem

Expanded problem focused: brief HPI, problem pertinent ROS.

Detailed: Extended HPI, problem pertinent ROS plus a limited number of additional systems. Pertinent PMFSH related to the patient’s problems.

Comprehensive: extended HPI, ROS that is directly related to the problems identified in the HPI plus all additional body systems, and a complete PMFSH.

 
FAQ 5. Are there differences between the CMS and CPT requirements for HPI?

Yes, as you see in the table below CMS has expanded upon the more general language for brief and extended HPI and adopted specific numerical requirements. CPT has 7 HPI elements, and CMS has 8 HPI elements.

E/M Level CPT 1995 CMS
99281, 99282, 99283 Brief 1-3 elements
99284, 99285 Extended 4 or more elements
 
FAQ 6. Are there differences between the CMS and CPT requirements for ROS?

Yes, as you see in the table below CMS has expanded upon the more general language for problem pertinent, extended, and complete ROS and adopted specific numerical requirements.

E/M Level CPT 1995 CMS
99281 Not required Not required
99282, 99283 Problem pertinent 1
99284 Extended 2-9
99285 *All Systems 10 or more

*The CMS Guidelines allow the statement "all other systems are negative" to suffice for a complete ROS provided pertinent positives and/or negatives are already documented.

 
FAQ 7. Are there differences between the CMS and CPT requirements for Past/Family/Social History?

Yes, as you see in the table below CMS has expanded upon the more general language for problem pertinent and complete Past/Family/Social History and adopted specific numerical requirements.

E/M Level CPT 1995 CMS
99281, 99282, 99283 Not required Not required
99284 Pertinent 1
99285 *Complete **2

*Of note, within the CPT definition of a Comprehensive history is the description:
"chief complaint; extended history of present illness; review of systems which is directly related to the problem(s) identified in the history of the present illness plus a review of all additional body systems; and a complete past, family and social history."

** For CMS, at least one specific item from two of the three history areas must be documented for a complete PFSH for the following categories of E/M services: office or other outpatient services, established patient; emergency department; subsequent nursing facility care; domiciliary care, established patient; and home care, established patient.

For CMS, at least one specific item from each of the three history areas must be documented for a complete PFSH for the following categories of E/M services: office or other outpatient services, new patient; hospital observation services; hospital inpatient services, initial care; consultations; comprehensive nursing facility assessments; domiciliary care, new patient; and home care, new patient.

 
FAQ 8. Are there any other important differences between CMS and CPT requirements for the History?

Yes. In the 1995 Documentation Guidelines, CMS makes general mention of situations where the physician is unable to obtain a history from the patient or other source when completing the History. "If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history."  A foreign language barrier does not qualify. Common examples include altered mental status, dementia, and also urgency of condition. However, the physician should make a "good faith" effort to gather the History from other sources and document as much as possible.  While CMS describes what ought to be documented in these situations, it makes no mention of any effect on E/M code selection.

CPT differs in that it states the components of the 99285 E/M service should be documented "within the constraints imposed by the urgency of the patient's clinical condition and/or mental status".  This is commonly referred to as the Level 5 acuity caveat, and can be applied to all the components of an E/M 99285 service including history, exam, and medical decision making.  CMS has not modified this CPT instruction.

CMS explicitly allows for the ROS and past history to be recorded by ancillary staff or the patient, as long as the practitioner documents he/she reviewed and supplemented and/or confirmed the information.

 
FAQ 9. How are the Exam components defined?

Exam documentation may be body area or organ system based, except a comprehensive exam which is based on organ systems only. The extent of documentation will depend on the nature of the presenting problem. Both CMS and CPT use the following definitions:

Problem focused (99281): a limited examination of the affected body area or organ system.

Expanded problem focused (99282 and 99283): a limited examination of the affected body area or organ system and other symptomatic or related organ system(s).

Detailed (99284): an extended examination of the affected body area(s) and other symptomatic or related organ system(s).

Comprehensive (99285): a general multi-system examination or a complete examination of a single organ system.

 
FAQ 10. Are there differences between the CMS and CPT requirements for Physical Exam?

The only official difference is the CMS DGs include a numerical requirement for a comprehensive exam.

The medical record for a general multi-system examination should include findings about 8 or more of the 12 organ systems.

While not "official" CMS guidelines, there are generally accepted numerical values for the other exam levels.

Problem Focused (99281) - 1 body area or organ system.

Expanded Problem Focused (99282, 99283) - 2-4 body areas or organ systems.

Detailed (99284) - 5-7 body areas or organ systems.

The numerical requirements for the Expanded Problem Focused Exam and the Detailed Exam were verbal instructions from the HCFA (CMS) Medical Director but were never officially included in the Medicare E/M Guidelines.  It is important to note that some CMS contractor policies may vary regarding the definitions of Expanded Problem Focused and Detailed Exams.  You are advised to check with your regional contractor.

 

 

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