When coding for a claim that will be submitted to Medicaid (depending upon the state) and/or Medicare, you must use the CMS 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.

CPT rules are generally less numerically concrete and allow the clinician some latitude based on the medical necessity of the particular clinical encounter. 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 carriers to audit charts by either CMS' 1995 guidelines or their 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 joint 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 complete 1995 guidelines are available on the CMS website at http://www.cms.hhs.gov/MLNEdWebGuide/25_EMDOC.asp. The Marshfield audit tool and other CMS carrier adaptations have further refined the application of guidelines to include numerical sub-element requirements.

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.

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.

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

Yes, as you see in the table below CMS has expanded upon the more general language for problem pertinent, extended, and complete ROS and conventionally adopted specific numerical requirements. CMS allows the statement "all other systems reviewed and are negative" to suffice for a complete ROS provided pertinent positives and/or negatives are already documented.

*Of note, within the CPT definition of a Comprehensive history is the description: "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".

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.

*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; 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.

Yes. CMS allows for situations where the physician is unable to obtain a history from the patient or other source when completing the History. If the patient is unable to give a history, the practitioner must 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. It is advisable for the physician to make attempts to gather the History from other sources and document as much as possible. CMS also allows for the ROS and past history to be recorded by ancillary staff or the patient, as long as the practitioner documents they reviewed and supplemented and/or confirmed the information.

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: a limited examination of the affected body area or organ system.

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

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

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

Yes, as you see in the table below CMS has specific numeric requirements for the Physical Exam.