ED Evaluation and Management Documentation Requirements – CMS vs. CPT

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, the guidelines you use will most likely depend upon whether or not you contractually 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 Evaluation and Management (E/M) guidelines are generally less quantitative, providing the clinician some qualitative latitude based on the medical necessity of a 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 contractors to audit physician documentation by either CMS' 1995 Documentation Guidelines (DG) or their 1997 DG, whichever most benefits the physician. The vast majority of Emergency Medicine physician groups use CMS' 1995 DG over the 1997 DG. Consequently, this FAQ will focus on the 1995 DG for CMS discussions. The complete 1995 Documentation Guidelines are available on the CMS website: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf. 

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. Subsequently, Medicare contractors adopted a variety of proxy tools to further qualify and quantify physician documentation elements toward supporting an Evaluation/Management level of service. Adaptations of the Marshfield Clinic Scoring tool and other CMS contractor audit tools seek to measure application of documentation guidelines across multiple physician specialties. 

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 components are considered the key components used in selecting the appropriate Emergency Medicine E/M service code. Note: Time is not a descriptive component for the emergency department levels of E/M services 99281-99285 in 2022. 

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 problem pertinent positives and/or negatives are 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 Medical/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 past medical, family, and social 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 (3 of 3) past medical, family, and social 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.

Both CMS and CPT use the descriptions in FAQ 9. Only the comprehensive exam has an official numerical requirement in the 1995 Documentation Guidelines for Evaluation & Management Services, "The medical record for a general multi-system examination should include findings about 8 or more of the 12 organ systems."

Within the coding industry there are recognized numerical values for the exam levels.

• Problem Focused - 1 body area or organ system
• Expanded problem focused - 2-7 body areas or organ systems
• Detailed - 2-7 body areas or organ systems
• Comprehensive - 8 or more organ systems

Most payers that publish their E&M policies or audit sheets indicate that Expanded Problem Focuses and Detailed both encompass 2-7 areas or systems, with the dividing line being the limited vs expanded exam of the affected area. The following are just a few examples taken from MAC websites:

1. CGS – Detailed physician exam includes extended exam of the affected body region or organ system.
2. NGS – Expanded Problem Focused – 2-7 areas of system (Minimal detail for areas/systems examined; check list documentation without any expansion of documentation findings.
3. NGS – Detailed - 2-7 areas of system (Expanded documentation of areas/systems examined; requires more than checklists; needs to have normal/abnormal finding expanded upon.
4. Novitas – recognizes the 2-7 areas or systems, but also includes a 4 x 4 method as an alternative. Novitas Evaluation and Management 4 x 4 Method

The CPT/CMS description of Problem Focused exam uses the phrase "examination of the affected body area or organ system" which is interpreted as Problem Focused exam requires 1 body area or organ system be examined.