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Evaluation and Management (E/M) services have many gray areas from an auditing standpoint, yet they continue to represent a top audit target for payers and the government. 

The documentation guidelines for E/M services are now 20 years old and have seen no significant changes. What has changed, however, is how the medical record is created, analyzed, and scored. 

What we have been left with are guidelines that are suggestive in nature and leave many areas open for interpretation by medical auditors across the industry. Auditors themselves differ widely in experience and training, which affects how they interpret the guidelines.  The interpretation of these areas may vary widely based on the experiences and training of the auditor.  In our recent National Alliance of Medical Auditing Specialists (NAMAS) salary survey, we found that 64 percent of respondents had been performing audits for less than five years. Of these respondents, 50 percent had been performing audits for less than two years. Many of these auditors have no formal training and rely on instructions they were given about the guidelines during on-the-job training that can vary widely in quality.

When I first began auditing, my job description did not include being an auditor, yet my daily tasks included reviewing providers’ E/M services and deciding whether the proper level of service had been assigned. If they were not correct, I would create a report (over-coding or under-coding report) that would be given weekly to the affected providers. Sounds like a great compliance program, unless you consider the fact that I was given an audit tool and one hour of training on how to select E/M levels of service. So while this was a great initiative, my results then were probably not the best way of ensuring consistent compliance. Just 15 or 20 years ago, when I began auditing, concepts like sampling, reviews, and compliance were barely on the radar for practices. Today, the stakes are much higher, making it all the more important for new auditors to receive comprehensive, in-depth training.

No single article can take the place of such training, but we can start by clarifying those areas of the E/M guidelines where no clear and consistent interpretation exists. Some of the Medicare carriers have attempted to do this on their own, but they can only speak for their individual areas of jurisdiction and many disagree with one another. While this article is not meant to tackle every gray area, we will cover some of the biggest ones. 

Chief Complaint

The best place to start is at the beginning: The chief complaint. While the chief complaint may seem like a simple interpretation and documentation of what the patient presents for on the given date of service, it can often lead to discrepancy among auditors. The chief complaint often includes documentation of the specific location of a problem (e.g., “left hip pain”). 

The problem: Some auditors would say that if the hip pain was the chief complaint of record, you couldn’t also count the “left hip” as a location for the history of present illness (HPI) element. To do so would constitute “double dipping,” in their view. While CPT®’s documentation guidelines do not specifically address “double dipping,” there are many the Centers for Medicare & Medicaid Services (CMS) and other payer guidelines that do address that issue, though usually in the context of using HIP elements for both the HPI and the review of systems (ROS) element. There is no guideline that definitely states whether elements of the chief complaint may or may not be used for HPI elements. 

The clarification: Does “left hip” effectively answer the question of location within the HPI element? What other terms could possibly be used to identify location? Some would argue for using “hip pain” as the chief complaint, saving the “left” to be used for location. While this may seem like splitting hairs, this argument is actually an example of a clear interpretation that can be used consistently from note to note. The HPI should demonstrate symptoms or defining elements of the chief complaint; the laterality, position, or specific point of the problem would fit this bill perfectly. If a patient reports chest pain, we would expect the HPI to specify whether this is chest wall pain, indigestion chest pain, or chest pain associated with a cardiac event. While there are no clearly defined guidelines for this point of ambiguity, this clarity point would rationalize the thought process of the auditor when evaluating the encounter. This is far from the only gray areas associated with the chief complaint, but we will move on to the HPI.

History of Present Illness

Providers can appropriately document this area by including elements that demonstrate the symptomology of the patient. These fit into qualifying elements such as location, quality, severity, etc. Alternatively, if these specific elements are missing from the note, the HPI can instead be comprised of documentation indicating the status of three chronic or inactive diseases.

The problem: Many auditors will not count status updates unless the documentation includes triggering terms such as “chronic,” “stable,” “improving,” or “worsening.” There are many ways to demonstrate the status of a patient’s condition without the use of these specific trigger words. CMS guidelines have made it clear that certain aspects of care or patient progression may be implied within the documentation, though the problem then becomes what exactly supports “implied.” For example, a provider documents three chronic problems such as hypertension, diabetes, and hyperlipidemia. This provider’s status update indicates:

  • Hyperlipidemia: increased triglycerides and taking Crestor
  • Hypertension: managed with Lopressor
  • Diabetes: stable on Metformin

Would you, as an auditor, consider all of these to be appropriate status updates of chronic conditions?  Many auditors’ findings would conclude that this record, while documenting three chronic problems, fails to include a status for each, because those trigger terms for status are missing. But what happens when we break them down and look for implied status? Hyperlipidemia has an implied statusas worsening with increasing triglycerides, while the hypertension is implied to be stable as it is currently “managed” with medication, indicating that it is controlled. Finally, the diabetes is very clear as it states “stable” with the specific medication.

The clarification: Although the status of the chronic conditions in this example appears vague at first, we were able to identify the status via the “implied” guideline. There is no rule about how detailed the status of any given condition needs to be, merely that the status is documented.


We have covered just two of the gray areas of the medical record with respect to the E/M guidelines, and there are many more. For example, how thorough must “location” be in order for to count? Is “severity” described only with a pain scale? Does the “modifying factor” have to include how the patient is doing with the attempted therapy, or just include the therapy? There are no easy, one-word answers to these questions, and these questions are just limited to the HPI.

All entities should have a clearly defined policy on how to handle all of the areas in a note. Having a clear policy ensures consistency in your auditor assessments and findings. If you have no policy, you have no consistency. If you are a seasoned auditor who knows these gray areas well, and you can articulate the rationale you use to interpret these areas, make sure you share them with other auditors, especially those new to the job.

Be a mentor and help provide the in-depth training needed to clean up these gray areas that we are still dealing with two decades after the E/M guidelines were written.

About the Author 

Shannon DeConda is the founder and president of the National Alliance of Medical Auditing Specialists (NAMAS) as well as the President of Coding & Billing Services and a Partner at DoctorsManagement, LLC. Ms. DeConda has more than 16 years of experience as a multi-specialty auditor and coder. She has helped coders, medical chart auditors, and medical practices optimize business processes and maximize reimbursement by identifying lost revenue. Since founding NAMAS in 2007, Ms. DeConda has developed the NAMAS CPMA® Certification Training, written the NAMAS CPMA® Study Guide, and launched a wide variety of educational products and web-based educational tools to help coders, auditors, and medical providers improve their efficiencies.

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