Focus on E/M services: Medically appropriate history and exam

Dec. 4, 2020 / By Jean Jones, CPC

So far in our Evaluation and Management Services blog series, we have gone over changes related to medical decision making (MDM), specifically changes to the first, second, and third elements. Today, I will dive into E/M changes related to medically appropriate history and exam.

It has taken more than 20 years to revise the Evaluation and Management guidelines. As coders and auditors, we will no longer have to battle bullets for outpatient office visits—what constitutes “timing” for HPI? Anyone? I was responsible for training clinicians on the 1997 exam elements. I have had several clinicians ask me why “bowel sounds” weren’t counted. Evaluation and Management leveling will now be solely based on either MDM or timing for outpatient office visits. The following changes will go into effect on January 1, 2021 relating to history and physical exam:

  • History and Physical Exam components will not be considered as a component in leveling outpatient office visits.
  • History and Physical Exam should still be performed and documented based on medical necessity.

Let’s look at the definition of medical necessity:

Medical Appropriateness or Medically Appropriate means health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate medical setting; and is the least costly of multiple, equally-effective, alternative treatments or diagnostic modalities.

Nothing has changed in the Medicare Manual: Medical necessity is still king! The only thing that changes for coders is that history and exam elements are not a factor in scoring the outpatient office visit. A paradigm shift is happening here – we are moving away from our bean counting to a merit-based system. My thoughts regarding documentation essentially remain the same: Documentation should make sense and tell a cohesive story with medical necessity at the core.  The absence of these two key will not eliminate the need for continuity of care or the ability for documentation to stand up in a court of law. The documentation should be reviewed and considered only from a clinical perspective:

  • Is it medically appropriate?
  • Does it make sense?
  • Can I defend it in a court of law?

History and Physical Examination are still very important pieces of clinical care and there is extensive information online regarding the necessity of a good history and physical exam. For example:

“History taking and empathetic communication are two important aspects in successful physician-patient interaction. Gathering important information from the patient’s medical history is needed for effective clinical decision making while empathy is relevant for patient satisfaction.”

The physical exam has been used for centuries and, according to Stanford, is essential in diagnosing a patient:

“The simple yet essential process of conducting the physical exam is “low hanging fruit.” With the ascendance of technology there began to be less and less emphasis on what is obviously on the body that you can easily diagnose.”

Stay tuned for the next blog in our E/M series.

Jean Jones is a coding analyst at 3M Health Information Systems.

Learn more about the 2021 E/M changes.