Clear, complete, and concise medical documentation is critical to providing patients with high quality and safe medical care. Medical documentation is also essential for accurate and timely payment for healthcare services. Qualifying for payment requires skillful application of the documentation guidelines for evaluation and management services published by the Center for Medicare and Medicaid Services(CMS).
This E&M coding cheat sheet for will help you determine the appropriate level of service for medical care provided using the system outlined by TrailBlazer Health Enterprises. Selecting the appropriate level of service will ensure you receive maximal reimbursement for the healthcare services you actually provide to your patients.
Healthcare providers in Texas, Virginia, Maryland, Delaware, and the District of Columbia must use the Trailblazer method for MDM determination. In general, it is more difficult to qualify for a higher MDM level under the Trailblazer rules.
The Medicare Evaluation and Management (E&M, E/M, or E M depending on your preference) Coding cheat sheet has scoring tools for the history, exam, and medical decision making elements that are required for all E&M encounters. This worksheet includes the scoring tools outlined in the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services published by CMS.
What are E&M Services?
E&M services are easily recognizable medical services such as a visit to urgent care, hospital admission, or daily rounds on people admitted to a hospital. These services have multiple levels which correspond to different levels of medical complexity, such as a ‘new outpatient visit – level 4’. Selecting the correct level of service is critical to being paid appropriately for the patient encounter. Medicare released guidelines on how to select the proper service level in 1995 and 1997. These E&M Documentation Guidelines serve as the rulebook for E&M coding for physicians in the USA.
Not all medical services are covered under the E&M Documentation Guidelines. Surgeries, lab tests, preventative medicine, counseling, and imaging studies have separate documentation rules.
What needs to be documented for E&M services?
The 1997 E&M Documentation Guidelines state that each patient encounter must include a medical history, examination, and medical decision making (MDM). Each documentation component requires certain types of information to be documented in the medical record.
Documentation Components from the 1997 Guidelines:
- Chief Complaint (CC)
- History of Present Illness (HPI)
- Past Family and Social History (PFSH)
- Review of Systems (ROS)
Medical Decision Making (MDM)
- The number of diagnosis or management options
- Amount and complexity of medical data reviewed
- Risk of significant complications, morbidity, or mortality
How can I use this E&M coding cheat sheet to improve medical billing?
Using this E&M coding cheat sheet will give you the confidence to bill at the highest level that is appropriate for the medical service you provided. This will maximize your clinical revenue and may help you identify ways to improve your documentation to reduce your RAC audit risk.
Selecting the appropriate level for E&M services is challenging for most physicians. Studies show that 30-80% of outpatient E&M services are under coded, representing millions of dollars of lost practice revenue per year [Holt 2010].
How does this E&M coding cheat sheet determine MDM level?
The E&M Coding/Audit Worksheet uses the method outlined in “Thinking on Paper: Guidelines for Documenting Medical Decision Making” by Robert L. Edsall and Kent J. Moore and the Trailblazer Health guidelines for MDM.
TrailBlazer is the Medicare carrier for Colorado, New Mexico, Oklahoma, Texas, and the Indian Health Service.
References for the TrailBlazer Health E&M Coding or Audit Worksheet
- Thinking on Paper: Guidelines for Documenting Medical Decision Making
- HGSA Documentation worksheet
- Holt J, Warsy A, Wright P. Medical decision making: guide to improved CPT coding. South Med J. 2010 Apr;103(4):316-22
- 1997 Documentation Guidelines for Evaluation and Management Services
- 1995 Documentation Guidelines for Evaluation and Management Services
- Trailblazer Health documentation worksheet (for CO, NM, OK, and TX)
Requirements to use this TrailBlazer Health E&M Coding Worksheet
This medical coding worksheet is in the Adobe PDF format, which requires the free Adobe Reader to function. With Adobe Reader, these worksheets can be filled out and printed as many times as you need.