# E&M guide for dermatology



## kristinemarie (Mar 21, 2017)

So my office manager has presented me with a "Components Required for Selecting E&M Codes" by Ellzey Practice Group. When I first started working in the Derm field she told me that the guidelines for E&M are different than general medicine. Is anyone familiar with this document from the Ellzey Practice Group? Also, the nurses or MA's who room the patient complete the CC and HPI and sign that area of the note. Yes, we still have paper charts.   Is that an acceptable practice, since I have learned that the HPI, needs to be completed by the NP, PA, or MD.
I have been told that I will need to audit the new NP's that we have starting in the clinic, and I would appreciate any tips, and tools for this for the derm speciality.
Thank you!


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## ellzeycoding (Mar 21, 2017)

I am familiar with this document.  I helped create it.  Let me give you some sources... 

The E/M guidelines are based on CPT and CMS guidelines... you can follow either '95 or '97 CPT guidelines.

The exam elements are for Dermatology.  The exam requirements _may _be different for other specialties.

Here is a link the E/M _specialty exam_ for Dermatology

http://emuniversity.com/PDF/Specialty_Exam_Dermatology.pdf

The Skin Exam is also described in the 1997 CMS Guideline starting on page 41 and it further describes on the bottom of page 42 how many elements are needed for each level of Exam.


Next is a link to the '95 and '97 Documentation requirements from CMS.

*1995 - *https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnedwebguide/downloads/95docguidelines.pdf

*1997 - *https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnedwebguide/downloads/97docguidelines.pdf


In regards to the *HPI*, it must be completed by the *provider*.  The ROS and PFSH can be completed by non-provider ancillary staff such as nurses and medical assistants.

In the 1997 Guidelines...

_On the page 6 of the 1997 CMS Guidlines it states...

• DG: The ROS and/or PFSH may be recorded by ancillary staff or on a
form completed by the patient. To document that the physician
reviewed the information, there must be a notation supplementing or
confirming the information recorded by others._


The CMS logic about the HPI is that it only states that the ROS and PFSH may be obtained by ancillary staff. Since the HPI is not listed, this means that the HPI must be recorded by the provider.

I hope this helps!


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## kristinemarie (Mar 22, 2017)

*Thank you!*

Thank you so much for all this information!







ellzeycoding said:


> I am familiar with this document.  I helped create it.  Let me give you some sources...
> 
> The E/M guidelines are based on CPT and CMS guidelines... you can follow either '95 or '97 CPT guidelines.
> 
> ...


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## kristinemarie (Mar 28, 2017)

*My office manager*



kristinemarie said:


> Thank you so much for all this information!



My office manager is determined that the MA's and RN's can document the CC and HPI, rather than the NP or MD.  She stated that as long as the Doctor/NP went over the note with the initialed that part of the note, that is sufficient.  What do I need to do to protect myself in case of an audit?


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## kristinemarie (Mar 28, 2017)

kristinemarie said:


> Thank you so much for all this information!




Mr. Ellzey,
My office manager still believes that it is ok for a MA, RN to document the CC and HPI, after I showed her what I found. She is determined that as long as the MD, NP writes "agree" and initials that part of the note that should be sufficient. What do I need to do to protect myself when doing review of notes on the new providers?


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## ellzeycoding (Mar 28, 2017)

I can only cite the sources provided.  She can draw her own conclusions, however my position is not an opinion but based on multiple sources.

If she believes this is the case, have her provide to some official source documentation from the carriers stating this is permissible.


Keep in mind that we're talking about the *HPI *having the strictest requirements.   A few sources say CC can be documented by a nurse or MA, because it's often in the patient's own words..  The PFSH, ROS, and vitals can be taken by a nurse, or MA and reviewed/initialed by the provider.

The AAPC agrees based on this as well

https://www.aapc.com/blog/27349-confirmed-billing-provider-must-document-the-hpi/


*More sources...*

http://www.aappublications.org/news/aapnewsmag/2016/05/31/Coding052716.full.pdf

_The reporting provider must gather and document the CC and HPI. While CMS documentation rules do not explicitly state this, CMS infers this by excluding the elements from the ancillary provider guidance_


https://emuniversity.com/HistoryofPresentIllness.html

_The physician MUST personally complete and record the HPI.  The HPI is the ONLY part of the history which CANNOT be recorded by ancillary staff._


Now there "may" be a few carriers (and it varies by state and by carrier) state that an MA or RN can take a _preliminary _CC or HPI, but that the provider has to record the final CC and HPI in greater detail.

Such as shown here... (again North Carolina Medicaid in this document).  This differs from CMS rules.

http://publichealth.nc.gov/lhd/docs/PartI-CodingDoc-061714.pdf

_Only the physician or midlevel provider conducting the E&M service can record the HPI. The HPI, Exam and Medical Decision Making are considered physician/provider work. In some cases the office/clinic nurse may document preliminary information concerning the CC (Chief Complaint) or HPI, but this is to be considered preliminary. The provider must document that he/she reviewed the CC/HPI in greater detail. _


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