Journal of Dermatology for Physician Assistants

The official journal of the Society of Dermatology Physician Assistants

The Legal and Audit Perspective of the Patient Medical Record

By Jaci J. Kipreos, CPC, CPMA, CDEO, CEMC, COC, CPCI

Jaci J. Kipreos, CPC, CPMA, CDEO, CEMC, COC, CPCI, has been working in the field of medical coding and auditing for over 30 years. She has been a Certified Professional Coder (CPC) since 1994, attained her Certified Outpatient Coder (COC) for facility-based coding in 2005, and is a Certified Professional Medical Auditor specializing in Evaluation and Management (E/M) Coding. She has expertise in coding for family practice, urgent care, obstetrics and gynecology, general surgery, and Medicare’s Teaching Physician Guidelines, with a particular emphasis on E/M guideline compliance. She has served on the American Academy of Professional Coders (AAPC) National Advisory Board and is past president of AAPC’s Richmond and Charlottesville, Virginia, local chapters. Kipreos is president of Practice Integrity, LLC, where she manages a national client list and provides compliance monitoring for provider documentation. She currently resides in San Diego, California.

Disclosures: The author has disclosed no potential conflicts of interest, financial or otherwise, relating to the content of this article.

Address for Correspondence: If you have a question or comment, we encourage you to send it to

Welcome to Compliance Corner, a new department dedicated to providing information and tools to help keep your healthcare documentation for coding and billing compliant. This new resource aims to help you navigate recent changes to Current Procedural Terminology® (CPT®) Evaluation and Management (E/M) guidelines for office visits, which became effective January 1, 2021. Written by the American Medical Association (AMA), these guidelines contain new methodology and new definitions, both of which affect the way you as providers document the account of the patient visit.

As is often the case with significant change, attempts to comprehend and adapt to new guidelines has set off a chain reaction of follow-up questions. Here, we will provide clinical examples to assist in the explanation of these new requirements to support the different levels of service of CPT office visit codes. We will also feature YOUR questions on all compliance-related topics along with answers that walk you through the rationale for each response. Compliance Corner will contain a selection Q&As from you, the readership. If you have a scenario or question, we encourage you to send it to for review. I’m excited to bring you the next installment of Compliance Corner in which we will discuss the legal and audit perspective of the patient medical record. We also feature a reader question.

From “Quantifiable” to “Medically Appropriate”
What does this mean and why is it at issue?
One significant change seen in the 2021 E/M guidelines for office and outpatient services is that “quantifiable elements” for history and exam are no longer required. The new guidelines require a “medically appropriate” history and exam. To discuss best practices for compliant documentation to support these new guidelines, we must first ask what this change means and what is at issue. Why does this “new” statement cause confusion? Why is there concern about the history and exam documentation? How is the information contained in medical records intended to be used and, do these new guidelines change these intents?

Typically, medical records are used as evidence in Professional Misconduct Prosecutions, lawsuits, hearings, or inquests, as components of external reviews, audits, and peer assessments, and in billing investigations. Going back to before 2021 and looking at the prior documentation guidelines, we can read what the expectation was for medical record documentation. The 1995 and 1997 Documentation Guidelines both made the following statement concerning medical record documentation of the patient encounter:

Medical record documentation is required to record pertinent facts, findings, and observations about an individual’s health history, including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high quality care. The medical record facilitates: 

• the ability of the physician and other healthcare professionals to evaluate and plan the patient’s immediate treatment, and to monitor his/her healthcare over time
• communication and continuity of care among physicians and other healthcare professionals involved in the patient’s care
• accurate and timely claims review and payment
• appropriate utilization review and quality of care evaluations; and collection of data that may be useful for research and education.

Do we believe any of this intent has changed with the 2021 documentation guidelines?
The 1995 and 1997 guidelines went on to further state what was anticipated to be a part of the patient medical record.

The principles of documentation listed below are applicable to all types of medical and surgical services in all settings. For Evaluation and Management (E/M) services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient’s status. The general principles listed below may be modified to account for these variable circumstances in providing E/M services.

1. The medical record should be complete and legible.
2. The documentation of each patient encounter should include:
• reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results;
(Medically Appropriate)
• assessment, clinical impression, or diagnosis; (Problems Addressed)
• plan for care; (Risk)
• date and legible identity of the observer.
3. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred. (Data)
4. Past and present diagnoses should be accessible to the treating and/or consulting physician.
5. Appropriate health risk factors should be identified.
6. The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented.
7. The CPT and ICD-9-CM codes reported on the health insurance claim form should be supported by the documentation in the medical record.

Why was this changed?
The 1995 and 1997 guidelines noted above really do seem to make good sense. They make sense clinically too. So, why has it changed?

The verbiage from the 1995 and 1997 guidelines became a formula that required quantification of how much history and how much exam, which led to a lot of confusion and even anger.

In the 2021 guidelines developed by the AMA, the medical record is still a legal record that should reflect the encounter with the patient. This legal health record should be able to achieve the following:

• Support the decisions made in a patient’s care
• Support the revenue sought from third-party payers
• Document the services provided as legal testimony regarding the patient’s illness or injury, response to treatment, and caregiver decisions
• Serve as the organization’s business and legal record

Does any of this change with the 2021 documentation guidelines?
The guidelines now suggest a medically appropriate history and exam to be documented when and if performed. Contrary to the old guidelines, the amount of history obtained and documented, and the amount or extent of exam performed and documented does NOT affect the final level of service for office visits (99202 – 99215).

Does this guideline suggest that a history and exam is NOT necessary since it has no bearing on the level of service?
The question to ask in response must be…Is this a legal or a coding/auditing question? To help decide our answer, we should consider what Medicare has stated in the past few years about the expectation of documentation in the medical record for office and other outpatient visits (99202 – 99215). This information can be found in the CMS Final Rule that is published in the late fall of each year and provides guidance for the following year.

CMS made the following statement, which went into effect in 2019 and remains in effect:

For established patient office/outpatient visits, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed.

Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so.

Additionally, we are clarifying that for E/M office/outpatient visits, for new and established patients for visits, practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information.

CMS made the following statement to go into effect in 2021;

The clinically outdated system for number of body systems/areas reviewed and examined under history and review will no longer apply, and the history and exam components will be performed when they are reasonable and necessary and clinically appropriate.

These statements allow us to have some understanding of the expectation of what is in the medical record and who may record that information. Consider the following thoughts and really think about how your own documentation may look to an auditor:

1. Has the provider documented their review of information documented by others?
2. Do we know who documented what in the medical record?
a. History, exam, and medical decision making (MDM)
3. For established patients, is it clear in the documentation what has changed or what pertinent information has not changed?
4. Who determines what is “relevant?”
5. Who determines what is “medically appropriate?”
a. Who should?

Documentation Risks
There are risks when documentation in the patient’s medical record does not clearly identify who documented the record and if the provider reviewed and updated information that had been entered by someone else. These new guidelines place less emphasis on the history and exam portion of the medical record. Does this imply that the legal aspect of the medical record has become less important? Consider these questions at your next practice meeting with compliance or legal or with your auditors. How should each of these statements be handled in an audit situation? The answers may vary based on if it is a clinician, auditor, compliance or legal, answering the question.

• What to do with contradictory information found in parts of history and exam
o Edema
o Past complaints, now resolved, per assessment and noted as positive in hx
• Cloned notes (hx and exam)
• Copy and Paste (hx and exam)
• No documentation to support the conditions noted in the assessment
• No current date of service (DOS information for the patient

Final Thoughts
When working with your compliance department, you may want to address the following items:

✔ Update any current policy concerning documentation to address language from the final rule 2019-2021
✔ Create a policy if needed
✔ Involve the medical director for consideration of ”medically appropriate”
✔ Is there a policy addressing cloning?
✔ Involve the group
✔ When working or meeting with your auditing team or coding team you may want to discuss the following;

1. Make sure everyone understands any policies from compliance prior to starting the audit.
2. Clearly state how the information in the history and exam will be “handled” during the audit.
3. If there are concerns based on the documentation found in the history and exam, how will those be addressed?

The medical record remains a legal record that should accurately reflect the encounter between the patient and the provider. This is true regardless of payer documentation guidelines. However, these guidelines do make have an impact when someone reviews your documentation to support a level of service. Consider what your documentation is saying about the status of the patient and the care you are providing on that date of service.

Thank you and happy documenting!

Your Burning E/M Coding Questions… ANSWERED

Question: I would like to make sure I am clear on one issue for 2021 E/M coding: If a patient comes in with a chief complaint of a new skin lesion that is documented in the HPI, then this lesion is biopsied, I know this visit becomes a procedural code only. However, let’s say after the biopsy the patient inquired about another lesion that is then diagnosed as a normal lesion, let’s say a seborrheic keratosis. They are counseled and reassured, and this plan is documented in the chart. However, because it was not a presenting problem, the provider did not go back and add this problem’s history/description to the HPI. Can this still be considered a 99212 office visit or must there be an HPI element for the seborrheic keratosis to be considered an addressed problem for the E/M code?

Answer: If the documentation would reflect that the SK was examined or a comment is made that it was looked at and it is noted that the patient asked about it and the discussion with the patient and reassurance is documented then this would support a separate visit with the 25 modifier. I believe you are correct it would be a 99212.

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