Components of evaluation and management

By Alexander Miller, MD, May 1, 2018

A Medicare patient new to you comes for a “skin check.” You do a complete skin examination and bill CPT^® 99203 for your efforts. Upon chart audit payment to you is rescinded and you are asked for a refund to your Medicare Administrative Contractor. What happened? You provided a legitimate service for free.

Why is the above scenario subject to non-coverage? Screening skin examinations are not a Medicare-covered service. Since the chief complaint entered in the patient’s chart record was “skin check,” that implied a screening examination, as no specific complaint was listed.

A Chief Complaint is a description of a symptom, problem, condition, diagnosis, or another reason for an encounter. This is usually presented in the patient’s words. A chief complaint is typically short, but potent in predicting coverage for a visit. In the above example, there was really no complaint at all. There was only a request for a skin examination predicated upon no expressed risk factors. If, however, the same encounter were expressed as, “I would like some spots checked,” it would imply concern about specific lesions. The history narrative could then more specifically expand upon the patient’s concerns, and such worry could be further validated by a past history of significant UV skin damage, a prior history of precancerous or cancerous growths, a family history of skin cancer, a personal or family history of atypical nevi, or other risk factors. In the absence of such, and particularly with a chief complaint of “skin check,” insurance coverage for a visit may be difficult to justify.

A documented chief complaint is a required component of each level of history taking: problem focused, expanded problem focused, detailed, and comprehensive. No chief complaint = insufficient documentation to justify an E/M visit charge.

The chief complaint is typically followed by a History of Present Illness (HPI). This is a narrative entered by the interviewer, the Qualified Health Care Professional (QHP), which lists chronologically the course of the presenting illness or illnesses. Such a description may include the following elements related to the illness:

• Location
• Quality (e.g., itching, stinging, burning, aching)
• Severity (e.g., on a scale of 1-10, or a descriptive account of severity)
• Duration (e.g., start time, total duration)
• Timing (e.g., continuous, constant, episodic)
• Context (e.g., associated activity, event related to complaint)
• Modifying factors (e.g., treatment response, activity)
• Associated signs and symptoms (e.g., other associated distinct signs/ symptoms)

HPI is stratified into two types: Brief and Extended.

A Brief HPI must include one to three documented elements from the above list.

An Extended HPI is reached by following either the 1995 or the 1997 documentation guidelines.

1995 guidelines: four or more elements of the HPI or associated comorbidities

1997 guidelines: four elements of the HPI or the status of three chronic or inactive conditions

The complete CMS E/M documentation guidelines can be viewed at www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf.

Example 1: A patient comes in with a chief complaint of “itchy rash.” HPI reveals that the rash started one month ago (duration) on the arms and trunk (location) as very (severity) itchy (quality) spots and bumps. Topical itch relief lotions have provided slight relief (modifying factors). You determine that this history qualifies as an extended HPI.

Answer: Correct. There are five HPI elements, specified in parentheses, in the above scenario. Since this exceeds the four-element threshold, an extensive HPI is reached.

Example 2: A patient comes in with acne well controlled with topical treatments, partially cleared warts, and foci of nummular eczema that have improved with topical steroids. Since there are only three stable conditions described, you determine a brief HPI level.

Answer: Incorrect. According to the 1997 documentation guidelines, a description of the status of three chronic conditions alone, without any separate HPI, elevates a visit to an extended HPI level. In the above example three pre-existing skin maladies are covered.

Example 3: Seven days following a diagnostic biopsy a patient comes in for suture removal. You document the suture removal and describe a discussion of the biopsy diagnosis and treatment plans based upon the diagnosis. What is missing from this documentation?

Answer: No chief complaint is listed. Consequently, upon audit the visit fee may be disallowed on the basis of an absent chief complaint. Sample chief complaint: “biopsy results discussion.” Since a biopsy has a zero-day global period, one may appropriately bill for a subsequent visit related to the biopsy.

Example 4: You examine a Medicare patient with a past history of non-melanoma skin cancer. The patient’s documented chief complaint is: “I’m here to have some spots checked for skin cancer.” You do a complete skin examination preceded by questioning about new or changing skin lesions, UV exposure and UV protection strategies, and any outside treatments received for skin lesions, and any self-treatment of lesions. You then code an appropriate Evaluation and Management (E/M) level of service with Z85.828 (Personal history of other malignant neoplasm of skin) for a diagnosis. You expect this to be a covered service.

Answer: Correct. The above patient record documents a reasonable and necessary need for your services predicated upon a past history of skin cancer, as such a patient retains a lifetime risk for further cancer production. If specific lesions were discovered and discussed during the course of the examination, those would be separately indexed as diagnoses linked to the E/M code.

Example 5: A new acne patient comes in for evaluation and treatment. You document an HPI pertinent to acne and proceed to do a complete skin examination, palpate lymph node basins, and examine the oral cavity. You list acne as the sole diagnosis for the visit. You appropriately include your physical examination elements in determining the level of E/M service provided.

Answer: Incorrect. Although you documented everything that was done, was palpation of lymph node basins, examination of the oral cavity, and a complete skin examination necessary for an acne evaluation? An audit would likely determine that such a service was not relevant to an acne diagnosis, and would not count these examined areas determining the level of E/M provided. 

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