1997 E&M

University of Florida
College of Medicine
Office of Compliance
1997 Documentation Guidelines For Evaluation & Management Services

TABLE OF CONTENTS These guidelines are available in a printer optimized Adobe PDF file. Click on the icon to download.

Introduction
        What Is Documentation and Why Is it Important?
        What Do Payers Want and Why?
General Principles of Medical Record Documentation
Documentation of E/M Services
Documentation of History
        Chief Complaint (CC)
        History of Present Illness (HPI)
        Review of Systems (ROS)
        Past, Family and/or Social History (PFSH)
Documentation of Examination
        General Multi-System Examinations
        Single Organ System Examinations
        Content and Documentation Requirements
              General Multi-System Examination
              Cardiovascular Examination
              Ear, Nose and Throat Examination
              Eye Examination
              Genitourinary Examination
              Hematologic/Lymphatic/Immunologic Examination
              Musculoskeletal Examination
              Neurological Examination
              Psychiatric Examination
              Respiratory Examination
              Skin Examination
Documentation of the Complexity of Medical Decision Making
        Number of Diagnoses or Management Options
        Amount and/or Complexity of Data to Be Reviewed
        Risk of Significant Complications, Morbidity, and/or Mortality
        Table of Risk
Documentation of an Encounter Dominated by Counseling or Coordination of Care

1997 DOCUMENTATION GUIDELINES
FOR EVALUATION AND MANAGEMENT SERVICES

I. INTRODUCTION

WHAT IS DOCUMENTATION AND WHY IS IT IMPORTANT?

Medical record documentation is required to record pertinent facts, findings, and observations about an individual's health history including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high quality care. The medical record facilitates:

The ability of the physician and other health care professionals to evaluate and plan the patient's immediate treatment, and to monitor his/her health
care over time.
communication and continuity of care among physicians and other health care professionals involved in the patient's care;
accurate and timely claims review and payment;
appropriate utilization review and quality of care evaluations; and
collection of data that may be useful for research and education.

An appropriately documented medical record can reduce many of the "hassles" associated with claims processing and may serve as a legal document to verify the care provided, if necessary.

WHAT DO PAYERS WANT AND WHY?

Because payers have a contractual obligation to enrollees, they may require reasonable documentation that services are consistent with the insurance coverage provided. They may request information to validate:

the site of service;
the medical necessity and appropriateness of the diagnostic and/or therapeutic services provided; and/or
that services provided have been accurately reported.

II. GENERAL PRINCIPLES OF MEDICAL RECORD DOCUMENTATION

The principles of documentation listed below are applicable to all types of medical and surgical services in all settings. For Evaluation and Management (E/M) services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient's status. The general principles listed below may be modified to account for these variable circumstances in providing E/M services.

The medical record should be complete and legible.
The documentation of each patient encounter should include:

reason for the encounter and relevant history, physical examination findings and prior diagnostic test results;
assessment, clinical impression or diagnosis;
plan for care; and
date and legible identity of the observer.

If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.
Past and present diagnoses should be accessible to the treating and/or consulting physician.
Appropriate health risk factors should be identified.
The patient's progress, response to and changes in treatment, and revision of diagnosis should be documented.
The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

III. DOCUMENTATION OF E/M SERVICES

This publication provides definitions and documentation guidelines for the three key components of E/M services and for visits which consist predominately of counseling or coordination of care. The three key components -- history, examination, and medical decision making -- appear in the descriptors for office and other outpatient services, hospital observation services, hospital inpatient services, consultations, emergency department services, nursing facility services, domiciliary care services, and home services. While some of the text of CPT has been repeated in this publication, the reader should refer to CPT for the complete descriptors for E/M services and instructions for selecting a level of service. Documentation guidelines are identified by the symbol •DG. The descriptors for the levels of E/M services recognize seven components which are used in defining the levels of E/M services. These components are:

history;
examination;
medical decision making;
counseling;
coordination of care;
nature of presenting problem; and
time.

The first three of these components (i.e., history, examination and medical decision making) are the key components in selecting the level of E/M services. In the case of visits which consist predominantly of counseling or coordination of care, time is the key or controlling factor to qualify for a particular level of E/M service.

Because the level of E/M service is dependent on two or three key components, performance and documentation of one component (eg, examination) at the highest level does not necessarily mean that the encounter in its entirety qualifies for the highest level of E/M service.

These Documentation Guidelines for E/M services reflect the needs of the typical adult population. For certain groups of patients, the recorded information may vary slightly from that described here. Specifically, the medical records of infants, children, adolescents and pregnant women may have additional or modified information recorded in each history and examination area.

As an example, newborn records may include under history of the present illness (HPI) the details of mother's pregnancy and the infant's status at birth; social history will focus on family structure; family history will focus on congenital anomalies and hereditary disorders in the family. In addition, the content of a pediatric examination will vary with the age and development of the child. Although not specifically defined in these documentation guidelines, these patient
group variations on history and examination are appropriate.

A. DOCUMENTATION OF HISTORY

The levels of E/M services are based on four types of history (Problem Focused, Expanded Problem Focused, Detailed, and Comprehensive). Each type of history includes some or all of the following elements:

Chief complaint (CC);
History of present illness (HPI);
Review of systems (ROS); and
Past, family and/or social history (PFSH).

The extent of history of present illness, review of systems and past, family and/or social history that is obtained and documented is dependent upon clinical
judgement and the nature of the presenting problem(s).

The chart below shows the progression of the elements required for each type of history. To qualify for a given type of history all three elements in the table must be met. (A chief complaint is indicated at all levels.)

History of Present
Illness (HPI) Review of Systems (ROS) Past, Family, and/or
Social History (PFSH) Type of History

Brief N/A N/A Problem Focused

Brief Problem persistent N/A Expanded Problem Focused

Extended Extended Pertinent Detailed

Extended Complete Complete Comprehensive

DG: The CC, ROS and PFSH may be listed as separate elements of history, or they may be included in the description of the history of the present illness.

DG: A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:

describing any new ROS and/or PFSH information or noting there has been no change in the information; and

noting the date and location of the earlier ROS and/or PFSH.

DG: The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.

DG: If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history.

Definitions and specific documentation guidelines for each of the elements of history are listed below.

CHIEF COMPLAINT (CC)

The CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the
encounter, usually stated in the patient's words.

DG: The medical record should clearly reflect the chief complaint.

HISTORY OF PRESENT ILLNESS (HPI)

The HPI is a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present. It includes the following elements:

location,
quality,
severity,
duration,
timing,
context,
modifying factors, and
associated signs and symptoms.

Brief and extended HPIs are distinguished by the amount of detail needed to accurately characterize the clinical problem(s).

A brief HPI consists of one to three elements of the HPI.

DG: The medical record should describe one to three elements of the present illness (HPI).

An extended HPI consists of at least four elements of the HPI or the status of at least three chronic or inactive conditions.

DG: The medical record should describe at least four elements of the present illness (HPI), or the status of at least three chronic or inactive conditions.

REVIEW OF SYSTEMS (ROS)

A ROS is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced.

For purposes of ROS, the following systems are recognized:

Constitutional symptoms (e.g., fever, weight loss)
Eyes
Ears, Nose, Mouth, Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary (skin and/or breast)
Neurological
Psychiatric
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic

A problem pertinent ROS inquires about the system directly related to the problem(s) identified in the HPI.

DG: The patient's positive responses and pertinent negatives for the system related to the problem should be documented.

An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems.

DG: The patient's positive responses and pertinent negatives for two to nine systems should be documented.

A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.

DG: At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented.

PAST, FAMILY AND/OR SOCIAL HISTORY (PFSH)

The PFSH consists of a review of three areas:

past history (the patient's past experiences with illnesses, operations, injuries and treatments);
family history (a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk); and
social history (an age appropriate review of past and current activities).

For certain categories of E/M services that include only an interval history, it is not necessary to record information about the PFSH. Those categories are subsequent hospital care, follow-up inpatient consultations and subsequent nursing facility care.

A pertinent PFSH is a review of the history area(s) directly related to the problem(s) identified in the HPI.

DG: At least one specific item from any of the three history areas must be documented for a pertinent PFSH .

A complete PFSH is of a review of two or all three of the PFSH history areas, depending on the category of the E/M service. A review of all three history areas is required for services that by their nature include a comprehensive assessment or reassessment of the patient. A review of two of the three history areas is sufficient for other services.

DG: 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; domiciliary care, established patient; and home care, established patient. [subsequent nursing facility care has been removed from this 1997 guideline]

DG: 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.

B. DOCUMENTATION OF EXAMINATION

The levels of E/M services are based on four types of examination:

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 any other symptomatic or related body area(s) or organ system(s).

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

Comprehensive -- a general multi-system examination, or complete examination of a single organ system and other symptomatic or related body area(s) or organ system(s).

These types of examinations have been defined for general multi-system and the following single organ systems:

Cardiovascular
Ears, Nose, Mouth and Throat
Eyes
Genitourinary (Female)
Genitourinary (Male)
Hematologic/Lymphatic/Immunologic
Musculoskeletal
Neurological
Psychiatric
Respiratory
Skin

A general multi-system examination or a single organ system examination may be performed by any physician regardless of specialty. The type (general multi-system or single organ system) and content of examination are selected by the examining physician and are based upon clinical judgement, the patient’s history, and the nature of the presenting problem(s).

The content and documentation requirements for each type and level of examination are summarized below and described in detail in tables beginning on page 13. In the tables, organ systems and body areas recognized by CPT for purposes of describing examinations are shown in the left column. The content, or individual elements, of the examination pertaining to that body area or organ system are identified by bullets (•) in the right column.

Parenthetical examples, “(eg, ...)”, have been used for clarification and to provide guidance regarding documentation. Documentation for each element must satisfy any numeric requirements (such as “Measurement of any three of the following seven...”) included in the description of the element. Elements with multiple components but with no specific numeric requirement (such as “Examination of liver and spleen”) require documentation of at least one component. It is possible for a given examination to be expanded beyond what is defined here. When that occurs, findings related to the additional systems and/or areas should be documented.

DG: Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. A notation of "abnormal" without elaboration is insufficient.

DG: Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or organ system(s) should be described.

DG: A brief statement or notation indicating "negative" or "normal" is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s).

GENERAL MULTI-SYSTEM EXAMINATIONS

General multi-system examinations are described in detail beginning on page 13. To qualify for a given level of multi-system examination, the following content and documentation requirements should be met:

Problem Focused Examination - should include performance and documentation of one to five elements identified by a bullet (•) in one or more organ system(s) or body area(s).

Expanded Problem Focused Examination - should include performance and documentation of at least six elements identified by a bullet (•) in one or more organ system(s) or body area(s).

Detailed Examination -- should include at least six organ systems or body areas. For each system/area selected, performance and documentation of at least two elements identified by a bullet (•) is expected. Alternatively, a detailed examination may include performance and documentation of at least twelve elements identified by a bullet (•) in two or more organ systems or body areas.

Comprehensive Examination -- should include at least nine organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet (•) should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least two elements identified by a bullet is expected.

SINGLE ORGAN SYSTEM EXAMINATIONS

The single organ system examinations recognized by CPT are described in detail beginning on page 18. Variations among these examinations in the organ systems and body areas identified in the left columns and in the elements of the examinations described in the right columns reflect differing emphases among
specialties. To qualify for a given level of single organ system examination, the following content and documentation requirements should be met:

Problem Focused Examination -- should include performance and documentation of one to five elements identified by a bullet (•), whether in a box with a shaded or unshaded border.

Expanded Problem Focused Examination -- should include performance and documentation of at least six elements identified by a bullet (•), whether in a box with a shaded or unshaded border.

Detailed Examination -- examinations other than the eye and psychiatric examinations should include performance and documentation of at least twelve elements identified by a bullet (•), whether in box with a shaded or unshaded border.

Eye and psychiatric examinations should include the performance and documentation of at least nine elements identified by a bullet (•), whether in a box with a shaded or unshaded border.

Comprehensive Examination -- should include performance of all elements identified by a bullet (•), whether in a shaded or unshaded box. Documentation of every element in each box with a shaded border and at least one element in each box with an unshaded border is expected.

CONTENT AND DOCUMENTATION REQUIREMENTS

General Multi-System Examination

System/ Body Area	Elements of Examination
Constitutional	Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be recorded and measured by ancillary staff) General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)
Eyes	Inspection of conjunctivae and lids Examination of pupils and irises (eg, reaction to light and accommodation, size, and symmetry) Ophthalmoscopic examination of optic discs (eg, size, C/D ratio, appearance) and posterior segments (eg, vessel changes, exudates, hemorrhages)
Ears, Nose, Mouth and Throat	External inspection of ears and nose (eg, overall appearance, scars, lesions, masses) Otoscopic examination of external auditory canals and tympanic membranes Assessment of hearing (eg, whispered voice, finger rub, tuning fork) Inspection of nasal mucosa, septum and turbinates Inspection of lips, teeth and gums Examination of oropharynx: Oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx
Neck	Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus) Examination of thyroid (eg, enlargement, tenderness, mass)
Respiratory	Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement) Percussion of chest (eg, dullness, flatness, hyperresonance) Palpation of chest (eg, tactile fremitus) Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)
Cardiovascular	Palpation of heart (eg, location, size, thrills) Auscultation of heart with notation of abnormal sounds and murmurs Examination of: Carotid arteries (eg, pulse amplitude, bruits) Abdominal aorta (eg, size, bruits) Femoral arteries (eg, size, bruits) Pedal pulses (eg, pulse amplitude) Extremities for edema and/or varicosities
Chest (Breasts)	Inspection of breasts (eg, symmetry, nipple discharge) Palpation of breasts and axillae (eg, masses or lumps, tenderness)
Gastrointestinal (Abdomen)	Examination of abdomen with notation of presence of masses or tenderness Examination of liver and spleen Examination for presence or absence of hernia Examination (when indicated) of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses Obtain stool samples for occult blood test when indicated
Genitourinary	MALE: Examination of the scrotal contents (eg, hydrocele, spermatocele, tenderness of cord, testicular mass) Examination of the penis Digital rectal examination of prostate gland (eg, size, symmetry, nodularity, tenderness) FEMALE Pelvic examination (with or without specimen collection for smears and cultures), including Examination of external genitalia (eg, general appearance, hair distribution, lesions) and vagina (eg, general appearance, estrogen affect, discharge, lesions, pelvic support, cystocele, rectocele) Examination of the urethra (eg, masses, tenderness, scarring) Examination of bladder (eg, fullness, masses, tenderness) Cervix (eg, general appearance, lesions, discharge) Uterus (eg, size, contour, position, mobility, tenderness, consistency, descent or support) Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity)
Lymphatic	Palpation of lymph nodes in two or more areas: Neck Axillae Groin Other
Musculoskeletal	Examination of gait and station Inspection and/or palpation of digits and nails (eg, clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes) Examination of joints, bones and muscles of one or more of the following six areas: 1) head and neck; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; 6) left lower extremity. The examination of a given area includes: Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions. Assessment of range of motion with notation of any pain, crepitation or contracture Assessment of stability with notation of any dislocation (luxation), subluxatoin or laxity. Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements.
Skin	Inspection of skin and subcutaneous tissue (eg, rashes, lesions, ulcers) Palpation of skin and subcutaneous tissue (eg, induration, subcutaneous nodules, tightening)
Neurologic	Test cranial nerves with notation of any deficits Examination of deep tendon reflexes with notation of pathological reflexes (eg, Babinski) Examination of sensation (eg, touch, pin, vibration, proprioception)
Psychiatric	Description of patient's judgement and insight Brief assessment of mental status including: Orientation to time, place and person Recent and remote memory Mood and affect (eg, depression, anxiety, agitation)

Content and Documentation Requirements

Level of Exam Perform and Document:

Problem Focused One to five elements identified by a bullet

Expanded Problem Focused At least six elements identified by a bullet

Detailed At least two elements identified by a bullet from each of six areas/systems OR at least twelve elements identified by a bullet in two or more areas/systems

Comprehensive Perform all elements identified by a bullet in at least nine organ systems or body areas and document at least two elements identified by a bullet from each of nine areas/systems.

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History of Present Illness (HPI)	Review of Systems (ROS)	Past, Family, and/or Social History (PFSH)	Type of History
Brief	N/A	N/A	*Problem Focused*
Brief	Problem persistent	N/A	*Expanded Problem Focused*
Extended	Extended	Pertinent	*Detailed*
Extended	Complete	Complete	*Comprehensive*

Level of Exam	Perform and Document:
Problem Focused	One to five elements identified by a bullet
Expanded Problem Focused	At least six elements identified by a bullet
Detailed	At least two elements identified by a bullet from each of six areas/systems OR at least twelve elements identified by a bullet in two or more areas/systems
Comprehensive	Perform all elements identified by a bullet in at least nine organ systems or body areas and document at least two elements identified by a bullet from each of nine areas/systems.