Evaluation and management (E/M) coding changed dramatically in 2021 when the three key components of history, exam, and medical decision making, were replaced/modified. Instead codes were to be selected by either time or medical decision making. The history and the exam took a back seat, at least in terms of code selection. However, they are still an essential part of the documentation. See part 1 of this series for an overview of the changes.
History and/or Examination
The history and examination are not elements which affect the choice of E/M code. The guidelines tell us that they should be “medically appropriate”, and the treating physician can determine the nature and extent of the history and examination. Information for the history can be gathered by the care team or a paper questionnaire, or an electronic health record portal, but it must be reviewed by the reporting physician. In a record that means that there must be some acknowledgement or statement by the provider that the information was considered.
One way to determine if you have documented sufficient history and examination is to consider what a panel of your peers would feel is “medically appropriate” for a patient in similar circumstances. Prior to 2021, these elements were laid out very specifically, and as such, it might useful to consider the old standard as a minimum amount of history and exam that might be used to meet a “medically appropriate” threshold.
For new patients, consider the following minimum elements (as borrowed from the 1995 E/M guidelines for a 99203) as a standard for a medically appropriate history for a typical chiropractic patient:
- Chief complaint (without one, the service would be a wellness visit, which often is not covered by third party payers)
- History of present illness (document at least 4, for each complaint):
- Location
- Quality
- Severity
- Timing
- Duration
- Context
- Modifying factors
- Associated signs and symptoms
- Review of systems (document at least 2):
- Musculoskeletal (could easily always include this one)
- Neurologic (easily included in a typical chiropractic setting as well)
- Condition specific relevant systems (such as skin, heart, lungs, etc.)
- Past, family, and/or social history (at least 1, but preferably 2)
The information for the history comes from the patient, in contrast to the information from the exam, which comes from the clinician. For a “medically appropriate” examination, consider that the old guidelines required an evaluation of at least two organ systems to reach a level 3 E/M code. Therefore, the minimum threshold for a typical chiropractic patient might be at least some documentation around a:
- Musculoskeletal exam
- Neurological exam
- Other relevant body systems (vitals, skin, etc.)
Please note that none of these elements are specially required per the updates to the guidelines in 2021, rather they are offered here as suggestions for how to establish a minimum standard in your office that would be easy to defend against a peer reviewer as “medically appropriate”.
Based on the 1995 rules for established patients, the requirements are not so stiff. You would still need a chief complaint, and updates to the elements of history of present illness that were documented at the new patient exam, but the other history elements do not need to be repeated, as they likely would be unchanged. The exam can include just one organ system, most likely the musculoskeletal, if the other systems examined previously were determined to not be relevant. But more systems can be included if they had positive findings at the previous exam.
Per the 2021 update to E/M codes, once the history and exam are taken care of, providers select the code based on time or medical decision making. The documentation should be roughly equivalent in either case, in terms of the standard of care, but there are advantages and disadvantages to each method. Each one is explored in Parts 3 and 4 of this post about evaluation and management coding and documentation for chiropractic.
Dr. Gwilliam is the Senior Vice President of Practisync, which helps practices improve efficiency and collect more through outsourced expert billing services. You can reach out to Dr. Gwilliam at evan.gwilliam@practisync.com.