What makes a good chart? How do you write a good chart quickly? How about a good, efficient, billable chart? On average, residents and practicing physicians report they did not receive adequate training in charting and coding1–3 and resident charts are more often down-coded due to documentation failures than those of attendings and PAs.4 Thankfully, resident education in charting has improved over the past 15 years,5 and a little learning goes a long way to improve confidence6 and competence.7
In the spirit of #FOAMed, we would like to provide some pearls and pitfalls for EM documentation, starting with a PV card that addresses the basic elements of coding a chart. We hope it’s a handy on-shift reference.
What is a CPT code? What is an E/M level?
In order to uniformly bill for services provided, the American Medical Association (AMA) maintains a list of Current Procedure Terminology (CPT) codes. When you provide medical services to a patient, the chart is billed using a CPT code based on Evaluation & Management (E/M) levels 1-5.8 Most ED visits are billed as E/M levels 3-5. In order to objectively categorize a chart, Centers for Medicare & Medicaid Services (CMS) created a coding system to assign an E/M level.
What is the difference between a lower and higher E/M level chart?
Three essential elements determine the E/M level: history, physical exam, and medical decision making (MDM). Each of these components is evaluated by a set of guidelines and categorized by the documented elements of the history/physical exam and complexity of MDM. After evaluating each essential element separately, all three are considered in choosing an E/M level and CPT code that is billed. The complexity of your MDM should ultimately determine your E/M level, but under-charting in another area will limit you from billing an appropriately high E/M level.
On your next shift, take a second to review your charts. Could one additional word in the history of present illness (HPI) bump a level 3 up to a level 4? Did you mention your chart biopsy, even if it was just skimming the most recent discharge summary or yesterday’s note? The following PV card outlines the minimum elements needed from all 3 areas required to code specific E/M levels, and shows that a single word or phrase may be the difference in clarifying a higher level of care provided.
Go to the ALiEM Cards site for more resources.
Keep an eye out for our follow-up posts. We’ll focus on individual sections of the chart (history, physical examination, MDM), specific diagnoses and special situations that require extra care when documenting.