The way medical charts are coded and billed is unnecessarily convoluted, and you have the Centers for Medicare & Medicaid (CMS) to thank for that. They are the ones who created the coding system that is used to assign an Evaluation & Management (E/M) level to our charts. Each chart is billed using a Current Procedure Terminology (CPT) code based on E/M levels 1-5.
Billing and coding is an extraordinarily boring topic. I’m actually impressed that you’ve read this far. But I think it’s worth taking a little time to understand the basics in order to chart as efficiently as possible. A level 5 chart does not necessarily require that you write a novel to meet the coding criteria. It is also possible to write a very long, thorough chart and still only get credit for a level 3 or 4 chart. Unless you know the elements of the chart that count towards that level of coding, you may end up doing a lot of unnecessary work.
Rather than review the criteria for every component of each of the 5 CPT codes, which would be time-consuming and painful for you to read, I thought it would be most beneficial to go through a sample level 5 (CPT code 99285) ED visit, pointing out the potential pitfalls where your chart could possibly be down-coded to a level 4.
There are only 3 components that determine the E/M level:
1. HISTORY
2. PHYSICAL EXAM
3. MEDICAL DECISION MAKING
As I go through this sample case I will demonstrate the minimum amount of documentation needed for the chart to be coded as a level 5 chart. I’m certainly not telling you to only document the minimum just to hit the level 5 criteria, as you should thoroughly chart everything that is necessary for each patient. This is simply an exercise to illustrate the minimum documentation that would be needed solely for coding purposes. Next to each of these 3 components, I will list in parentheses the minimum criteria required for that particular component. Keep in mind that the lowest scoring of the 3 components will determine the E/M level for the entire chart.
HISTORY (HPI: Chief Complaint, 4+ elements, ROS: 10+ elements, PFSH: 2 of 3 elements)
The history component consists of 4 elements: chief complaint (CC), History of present illness (HPI), Review of systems (ROS), and Past medical, family and social history (PFSH). A level 5 chart is designated “comprehensive” and includes 4+ HPI elements, 10+ ROS elements, and 2 of the 3 PFSH elements. What do you do if the patient is unable to provide a history because they are altered or intubated? Or what if the patient refuses to give a history? Add a qualifier describing the reason for the limitation, such as “patient is unable to provide history secondary to…”. This will apply to all elements of the history component.
- CC – This is a mandatory element for all charts, regardless of CPT level.
- HPI – A level 5 chart requires a minimum of 4 HPI elements*. You can include more, but you need at least 4. The HPI elements include
- Location
- Duration
- Timing
- Severity
- Quality
- Context
- Modifying Factors
- Associated Signs/Symptoms
*In lieu of the HPI elements you could also document the status of 3 chronic or inactive conditions.
- ROS – There are 14 organ systems recognized by CMS
- Constitutional
- Eyes
- Ears, Nose, Mouth, Throat
- Cardiovascular
- Respiratory
- Gastrointestinal
- Genitourinary
- Musculoskeletal
- Integumentary (skin and/or breast)
- Neurological
- Psychiatric
- Endocrine
- Hematologic/Lymphatic
- Allergic/Immunologic
A level 5 chart must document at least 10 organ systems. Your EMR may have a button you can click that states something to the effect “all other systems reviewed and are negative.” Clicking this button will technically satisfy the 10+ organ system ROS criteria, but doing so attests that you actually reviewed every organ system with the patient. A word of caution: don’t document something that you didn’t do!
- PFSH – This consists of 3 distinct components:
- Past Medical History (PMH) – Includes experiences with illnesses, operations, injuries, and treatments.
- Family History (FH) – Review of medical events, diseases, and hereditary conditions that may place the patient at risk.
- Social History (SH) – Includes sexual history, alcohol/drug use, employment, and education.
A level 5 chart must include at least one item each from 2 of the 3 components. These are often documented by another staff member, such as the triage nurse. If these are documented by another staff member they still counts toward your coding as long as you attest that their notes were “reviewed and verified by me.”
Let’s get to the sample case:
John Doe is a 60yo male with a history of hypertension and diabetes who presents to the emergency department complaining of chest pain. He describes the pain as a “pressure” sensation in his left chest that began at 4pm today while walking. He notes that his father died of an MI at age 65.
This brief paragraph includes the chief complaint (chest pain), 4 HPI elements: quality (“pressure”), location (left chest), duration (began at 4pm), and context (while walking); past medical history (history of hypertension and diabetes) and family history (father died of an MI at age 65). As long as you include your 10 ROS elements, you’ve met the minimum level 5 criteria for the HISTORY component of the chart! If this were a real patient you would clearly want to include more details regarding his presentation, but again, I’m using this example just to illustrate that you don’t need to write a novel for your chart to be coded at a level 5.
Pitfall – Keep in mind that the PFSH consists of 3 distinct components: PMH, FH and SH. You could list 10 medical conditions that the patient is suffering from but these all only count for 1 of these elements, the PMH. If the entire chart meets criteria for a level 5 chart but only 1 of these 3 elements is documented, such as failing to document that the patient is a smoker or has a significant FH of heart disease, the HISTORY component of the chart will be downcoded to a level 4, which means the entire chart is downcoded to a level 4.
PHYSICAL EXAM (9 systems, with 2 bullets per system)
A level 5 chart requires a “comprehensive” physical exam, which consists of 9 systems, with 2 bullets per system. CMS recognizes the following 14 systems as part of the physical exam:
- Constitutional
- Eyes
- Ears, Nose, Mouth and Throat
- Neck
- Respiratory
- Cardiovascular
- Chest (Breasts)
- Gastrointestinal
- Genitourinary
- Lymphatic
- Musculoskeletal
- Skin
- Neurologic
- Psychiatric
If you’d like to see the bullets that are within each of these systems, they can be found at the CMS website here. I’ve found that the most efficient way to ensure that your chart meets level 5 coding criteria is to create a “normal” templated exam that includes the minimum 9 systems with 2 bullets per system and modifying it as needed. However, if you choose to do this, be cautious! You need to know exactly what is in your templated exam and you must review it for each patient to ensure that you have not documented something that you did not actually do. Again, don’t document something that you didn’t do.
MEDICAL DECISION MAKING (High)
The MDM section of your note is the most nebulous of the 3 components when it comes to understanding how it is coded. There are 3 elements that are considered here, with the final code being based upon the highest 2 of the 3 following elements:
- The number of possible diagnoses and/or the number of management options that must be considered (I will refer to this as DIAGNOSES)
- The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed (I will refer to this as DATA)
- The risk of significant complications, morbidity and/or mortality, as well as comorbidities, associated with the patient’s presenting problem(s), the diagnostic procedure(s) and/or the possible management options (I will refer to this as RISK)
DIAGNOSES – The highest score for this category is “extensive,” which is needed to bill as a level 5 chart. If you are seeing a patient who is presenting with a problem that is new to you, the provider, and you are pursuing a workup of the presenting problem, this fulfills the “extensive” criteria. If you are seeing the same patient, but not pursuing any workup, this component would be categorized as “multiple” rather than “extensive” and coded as a level 4 rather than a level 5. As an emergency provider, nearly every patient you treat will be presenting with a problem that is new to you. A rare exception to this may be someone who is returning for a scheduled re-check.
DATA – Again, the highest score for this category is “extensive,” which corresponds to a level 5 chart. This section is calculated using a scoring system, with a score of 4 or greater needed to be considered “extensive.” Here is the breakdown of the scoring :
- Review and/or order of clinical lab tests – (1 point)
- Review and/or order of radiology tests (excluding cardiac cath and echo) – (1 point)
- Review and/or order of medical tests (PFTs, colonoscopy, cath, echo) – (1 point)
- Discuss tests with performing physician (e.g., You discussed a colonoscopy result with the gastroenterologist. You must document this discussion in your note.) – (1 point)
- Independent review of image, tracing, specimen* – (2 points)
- Reviewed and summarized old records or history from a person other than the patient (e.g., If you spoke with a consultant, even informally, this counts! Just be sure to document the conversation in your note.) – (2 points)
*If documenting an ECG, your interpretation must include at least 3 of the 6 elements: rate/rhythm, axis, intervals, ST-segment changes, comparison to prior, summary of the patient’s clinical condition
RISK – Level of risk is scored from “minimal” to “high,” with a score of “high” needed to bill as a level 5 chart. The risk score is calculated using a risk table, which is unwieldy and probably not worth your time to study. For our purposes, to understand what qualifies as a level 5 chart in the ED, suffice it to say that a patient who is sick and requires urgent intervention typically qualifies as a “high” level of risk. Conditions that fall under this category include acute MI, pulmonary embolism, severe COPD exacerbation, multiple trauma, seizure, CVA, and psychiatric patients who are a threat to themselves or others. Also note that any patient who receives a parenteral-controlled substance qualifies as “high” risk.
Let’s revisit our patient who is presenting to the ED with chest pain. His chief complaint is a problem that is new to us. If we decide to pursue a workup for his chest pain (e.g., labs, ekg, cxr, etc.), the DIAGNOSES component of the MDM would meet the “extensive” criteria. Now, in order for the MEDICAL DECISION MAKING element of the chart to qualify for level 5 billing, we just need either the DATA or RISK component to also meet the threshold for a level 5 chart. Remember, you need 2 of the 3 components of the MDM (DIAGNOSES, DATA and RISK) to satisfy the highest level of billing in order for the MDM element to be billed as a level 5 chart.
Remember, the DATA component of the MDM is calculated based on points derived from various elements of the workup. We need at least 4 points to satisfy the “extensive” level of billing required for a level 5 chart. For this patient, if we order labs (1 point), a chest x-ray (1 point), and then document our interpretation of the chest x-ray (2 points) we have a total of 4 points, which is sufficient to reach the “extensive” level of billing for the DATA component.
At this point the MDM element of the chart satisfies the billing criteria for a level 5 E/M code because 2 of the 3 elements of the MDM, the DIAGNOSES and DATA components, meet the maximum level of billing. The RISK component of the MDM does not even need to be considered because the MDM can be billed as a level 5 chart without it. However, if you had treated your patient’s chest pain with morphine during the encounter, this would have automatically bumped the RISK component to the maximum level, “high.” If this were the case, all 3 of the MDM elements would satisfy the criteria for a level 5 chart, though only 2 of these 3 are needed.
SUMMARY
To recap, a level 5 E/M chart requires that all 3 components of the chart, the HISTORY, PHYSICAL EXAM, and MDM, meet their respective maximum coding criteria. Here are the 3 components with their respective level 5 billing criteria and the items from the chart that fulfill them:
CRITICAL CARE TIME
Critical care documentation is a special snowflake that warrants its own section. CMS defines critical care as a medical condition that “impairs one or more vital organ systems” and is one in which “there is a high probability of imminent or life-threatening deterioration in the patient’s condition.” They further note that the physician should provide “frequent personal assessment and manipulation” of the patient’s condition.
Here is a list of diagnoses that suggest critical care billing may be appropriate:
- Active seizures
- Acute altered mental status
- Acute GI bleed
- Acute psychosis with agitation
- Acute stroke
- Cardiac arrest
- Delirium tremens
- DKA
- Ectopic pregnancy
- Hyperkalemia requiring treatment
- Hypovolemic shock
- Intracerebral hemorrhage
- Moderate to severe asthma
- Moderate to severe CHF
- Overdose requiring antidotes or reversal agents
- Pneumothorax
- Pulmonary embolus
- Rapid atrial fibrillation
- Respiratory distress requiring non-invasive positive pressure ventilation
- Respiratory distress requiring intubation
- Sepsis
- Severe anemia requiring blood transfusion
- STEMI
- Suicidal ideation immediate threat
- SVT
- Unstable angina
In addition to the patient having a critical condition, in order to bill for critical care time, you need to have spent 30 minutes or more on patient care. This includes time spent on direct patient care, as well as time spent on indirect patient care. Indirect patient care may include documentation, reviewing prior records, and speaking with consultants, paramedics, and family members. It is important to note that critical care time does not include time spent on procedures that are billed separately, such as intubations and central lines.
Some critically-ill patients may not qualify for critical care billing. If a patient with a STEMI is brought in by ambulance and then whisked off to the cath lab within 10 minutes of arrival, they would typically not qualify for critical care billing, regardless of how unstable they were. At least 30 minutes of time must be spent on patient care to bill for critical care.
If you care for a patient who meets the criteria for critical care billing and document it as such, these CPT codes (99291 for the first 30-74 minutes, 99292 for each additional 30 minutes beyond the first 74 minutes) supercede all of the elements discussed above for coding a E/M level 5 chart. Meaning, if you didn’t document a social history and your ROS only includes 8 organ systems instead of the 10 required for a level 5 chart, it will still be billed as a critical care chart.
Keep in mind that some patients may appear clinically stable but still qualify for critical care billing. The hyperkalemic patient who requires treatment, monitoring and frequent reassessments may qualify. As may the asthmatic who requires BiPAP and frequent reassessments.
Congrats on making it to the end! I hope this has been helpful. If you have any feedback for me regarding this article please contact me at theefficientmd@gmail.com.
Efficient MD
Disclaimer: This article was written for informational purposes only. I cannot guarantee the accuracy of the information provided. Payment policies can vary from payer to payer. I assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of, or relating to, the use, non-use, interpretation of, or reliance on information contained here. Specific coding or payment related issues should be directed to the payer.