Documentation for Evaluation and Management (E/M) Services

According to WPS, when billing or coding for E/M services you should follow a few guidelines.

Documentation must support the level of service billed and the medical necessity for the level billed. Below are additional tips for services which commonly incur CERT error findings for insufficient documentation.

Critical Care Visits 

• Clear indication of patient name, date of birth, and date of service 
• Signed progress note which includes documentation of the total time the physician spent evaluating, providing care and managing the critically ill or injured patient's care 
• Documentation to support the service provided was medically necessary and meets the definition of critical care as; the direct delivery by a physician(s) medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition 
• Reminder: The billing provider is responsible for providing medical records upon request, regardless of where the services were rendered 

Established patient office visit - CPT 99211 

• Clear indication of patient name, date of birth, and date of service 
• Documentation that the service is medically necessary for the diagnosis and treatment of an illness or injury 
• If billed in addition to blood draws, lab services, etc., there must be documentation that a separately identifiable face to face E/M service took place 
• A face to face encounter with a patient consisting of elements of both evaluation and management is required. 
  • 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.).

Hospital Discharge Day Management 

• Clear indication of patient name, date of birth, and date of service 
• Signed progress note which includes documentation of required face to face encounter with the patient 
• As applicable; note should also include documentation of: final examination of the patient, discussion of hospital stay, instructions to caregivers, and preparation of discharges records, prescriptions and referral forms 
• Documentation of time spent providing services - imperative if billing for more than 30 minutes (CPT code 99239) 
• Reminder: The billing provider is responsible for providing medical records upon request, regardless of where the services were rendered

Skilled Nursing Facility Care 

• Clear indication of patient name, date of birth, and date of service 
• Signed and legible physician progress note that documents a face-to-face encounter with the patient occurred 
• Documentation that supports the specific level of E/M visit billed 
• Signed and dated physician orders if applicable 
• Reminder: The billing provider is responsible for providing medical records upon request, regardless of where the services were rendered 

Subsequent Hospital Visits 

• Clear indication of patient name, date of birth, and date of service 
• Signed and legible physician progress notes for all dates billed 
• Physician progress note must document a face-to-face encounter with the patient took place 
• Documentation must support level of evaluation and management service billed 
• Signed physician orders as applicable 
• Reminder: The billing provider is responsible for providing medical records upon request, regardless of where the services were rendered 

Please be aware that this list is not all inclusive. Providers should submit all documentation to support the medical necessity and level of service(s) billed in accordance with Medicare regulations and policies.

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