2. E & M- The exchange of clinically reasonable
and necessary information between the
patient/caregiver/family and the use of the
information in the management of the patient
Information:
◦ History & Physical
◦ Progress Notes
◦ Discharge Summary
3. Culmination of Information
◦ History
Chief Complaint-Nature of Presenting Problem
History of Present Illness
PFSH & ROS
◦ Physical Exam
Body areas & Organ systems- based upon nature of
presenting problem and clinical judgment
4. Culmination of Information
◦ Medical Decision-Making
Proxy for medical necessity
Thought processes of physician
Complexity of arriving at a diagnosis(es) and/or
management action plan
Recording clinical judgment
Assessment of a patient’s particular clinical scenario and
the initiation of action congruent with the assessment
Clinical criteria used in your thought processes and
analytical skills
Work performed in arriving at diagnoses and chosen care
plan
5. Unequivocal need for patient care regardless
of service rendered and/or ordered
Physician responsibility and control
◦ Insurance determines based upon available
documentation
6. Determine the level of care necessary to
address patient’s presenting problem(s)
◦ Nature of presenting problem (CC)
◦ History of Present Illness
Signs and Symptoms
Clinical Context
Potential body areas or organ systems associated with
signs and symptoms
7. Provide the care necessary to meet but not
exceed the patient’s needs that you have
identified
Perform accurate, concise and complete
documentation capturing and reflecting your:
◦ Clinical judgment
◦ Thought processes, analytical and problem solving
skills
◦ Clinical reasoning, rationale and criteria
◦ Specificity in diagnoses including provisional and
definitive diagnoses
◦ Plan of care congruent with assessment
8. Words to the wise
◦ The word 'cloning' refers to documentation that is
worded exactly like previous entries. This may also
be referred to as 'cut and paste' or 'carried forward.'
◦ Cloned documentation may be handwritten, but
generally occurs when using a preprinted template
or an Electronic Health Record (EHR).
◦ While these methods of documenting are
acceptable, it would not be expected the same
patient had the same exact problem, symptoms,
and required the exact same treatment or the same
patient had the same problem/situation on every
encounter.
9. Each document must be specific to the
beneficiary and date of service rendered.
Cloning of documentation will be considered
misrepresentation of the medical necessity
requirement for coverage of services.
Cloned documentation does not meet medical
necessity requirements for coverage of services.
Identification of this type of documentation will
lead to denial of services for lack of medical
necessity and recoupment of all overpayments
made.
