Documenting the E/M Outpatient Visit

As you have trained, researched, debated and questioned how to use the 2021 E/M Guidelines, what are the key changes you plan to train your providers on?

One of our expert auditors, Jill Young, CEMA, CPC, CEDC, CIMC has suggested that a narrative note could be very effective to a) tell the story of the patient, b) be concise and clinical, documenting and showing the intensity of care considered and provided and c) justify medical necessity of the level of service provided.

Thomas Robey, MD, PhD in his article “The Art of Writing Patient Record Notes”  in July 2011 edition of the AMA Journal of Ethics says:

“Do you remember the last time you read an excellent physician note? If it was similar to any of the gems I’ve discovered, it was well organized and included the pertinent data from the encounter, all the while keeping the patient at the center of the dialogue. Good notes facilitate continuity of care, since many physicians gather background information in the electronic medical record (EMR) prior to meeting a new patient.”

As one of our event participants stated, the 2021 E/M coding guidelines can be supported by a return to documenting as a SOAP note. To support outpatient E/M services, the note should document the intensity of service, the intensity of assessment and treatment plan.

There are a myriad of articles on the topic of writing good visit notes. There is also a growing interest by patients and caregivers to be involved in their care.

So how should you educate your providers to write their notes in today’s world of patient portals and provider / patient communication?

Here is one commentary by Jared W. Klein, MD, MPH, et al in The American Journal of Medicine, Vol 129, No 10, October 2016.

  • Be clear and succinct
  • Directly and respectfully address concerns
  • Use supportive language
  • Include patients in the note-writing process
  • Encourage all patients to read their notes
  • Ask for and utilize feedback
  • Be familiar with how to amend notes

Hannah Chimowitz and Leonor Fernandez, MD, recommend in their article “Sharing Visit Notes: Getting Patients and Physicians on the Same Page” in AAFP’s Family Practice Management. 2016 Nov-Dec;23(6):10-13.

  • Be transparent.
  • Minimize jargon and abbreviations, especially any that patients might easily misinterpret.
  • Briefly define or simplify medical terms, such as short of breath, rather than SOB or dyspneic.
  • Highlight the patient’s strengths and achievements in addition to his or her symptoms.
  • Describe behaviors

Additional guidance may be found on your MAC’s website. Here are some documentation tips from WPS GHA. In their introduction of documentation tips for E/M coding, WPS GHA reminds the reader (bold font is theirs) “Evaluation and Management (E/M) Services Documentation must support the level of service billed and the medical necessity for the level billed.“

Medicare requires a face-to-face encounter with a patient consisting of elements of both evaluation and management.

The evaluation portion is substantiated when the record includes documentation of a clinically relevant and necessary exchange of information between provider and patient.

The management portion is substantiated when the record demonstrates an influence on patient care (ex.; medical decision making, patient education, etc.).

Novitas provides the following FAQ to the question about documenting history and exam.

8. Is the documentation of history and examination required when scoring office/outpatient services under the revised 2021 guidelines?

The approved revisions do not materially change the three current MDM elements, but instead provide extensive edits to the elements for code selection and revised or created numerous clarifying definitions in the E/M guidelines.

While the provider’s work in capturing the patient’s pertinent history and performing a relevant physical exam contributes to both the time and medical decision making, these elements alone should not determine the appropriate code level.

The revised code descriptors state a “medically appropriate history and/or examination” is required.

An additional benefit to a clear note that supports the medical necessity for the service – is that it can help to improve coding the encounter – whether you are new to the field of coding or a highly experienced auditor. 

What are your thoughts on using this type of encounter documentation?

What other documentation methods might be useful?

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