Journal of Dermatology for Physician Assistants

The official journal of the Society of Dermatology Physician Assistants

Healthcare Documentation Review and Reminders


Welcome to Compliance Corner, a department dedicated to providing information and tools to help keep your healthcare documentation for coding and billing compliant. This 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.

How are You Getting Along with the 2021 Documentation Guidelines?
Wow! It has already been a year since the AMA released the 2021 Documentation Guidelines. It would seem appropriate to check in with some reminders of what is important for the documentation of Medical Decision Making and time.

As I am sure you remember, medical decision making is comprised of three key areas, each with specific terminology and levels of complexity. Here are some questions you may want to ask yourself before completing your office note and submitting a claim.

The Three Parts of  Medical Decision Making
The Complexity of the Problems Addressed

1. Does your documentation indicate if the condition is chronic or acute?
2. If this is a chronic condition, are the individual goals that were established as part of the treatment plan being met?
a.) Does your documentation indicate the goal and the status of the condition?
b.)Would an auditor know if the chronic condition was stable or not improving?
3. If this is an acute condition, does your documentation indicate if this is an uncomplicated or complicated acute condition?
a.) Does your documentation indicate if this acute condition will resolve on its own?
b.) Does your documentation provide information concerning any long term affects from this acute condition?
4. If multiple conditions are addressed, is there a status and plan for each condition?

The Complexity of Data Reviewed and Analyzed
Does your documentation accurately reflect any of these key points? Would someone reviewing your documentation be able to give you credit for any of the below data items?

1. If external data is reviewed that must be evident in the documentation. External refers to any source outside of the group or practice.
a.) External data could be notes from a referring provider or a provider from another specialty or group that is also participating in the care of the patient.
2. Labs, that are results only, that are performed in the office and are reported by the group may count as one point for either the order or the review.
a.) If labs are ordered and performed elsewhere, each will still be counted as one point for either the order or the review.
b.) The documentation should reflect the source of the lab data.
i.) If the lab was ordered by an external source, then the review of those labs will count toward the complexity of data.
c.) When labs are reviewed, the documentation should reflect how that value or information was used in the decision-making process.
3. Complexity of data also gives credit for conversations with external sources such
as other providers who are external to the practice. The documentation should indicate which external provider will be contacted and the reason for the discussion.
a.) The discussion must be verbal not written, such as email, and it must be between the two providers not any of their ancillary staff.

The Risk of Management Options—Reminders about your documentation
1. The AMA has indicated that this risk is based entirely on the risk to the patient based on treatment options that are considered and or suggested at that encounter. This treatment risk is not to be confused with risk associated with the condition.
2. If the risk of any treatment is discussed with the patient, that should be indicated in the documentation.
3. The AMA has stated that the term “risk” is used to indicated risk that is unique to that patient due to the treatment plan discussed.
4. If the condition poses a risk to the patient, that risk is considered under Problems Addressed.
5. The documentation should clearly indicate any risk to the patient
a.) Defining “risk”
i.) If the patient is obese or is a smoker and this will add risk to their recovery or ability to improve, this should be documented.
ii. If the patient has co-morbid conditions that make it necessary to change a treatment plan, that should be documented.
6. If the treatment is over-the-counter medications, without any documentation of extenuating circumstances, then the overall risk will be considered low complexity risk.

Time-Based Documentation
The AMA updated the language for time-based coding and now allows for the total time on the date of service to be used when selecting the level of service. As with any CPT code reported, there must medical necessity to indicate what was performed during that time.

Examples of Typical Activities that Count Toward Time:

✔ Preparing to see the patient (e.g., review of tests)
✔ Obtaining and/or reviewing separately obtained history
✔ Performing a medically appropriate examination and/or evaluation
✔ Counseling and educating the patient/family/caregiver
✔ Ordering medications, tests, or procedures
✔ Referring and communicating with other healthcare professionals (when not separately reported)
✔ Documenting clinical information in the electronic or other health record
✔ Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver
✔ Care coordination (not separately reported)

The documentation should not be just a statement of total time. The activities that took place must be documented to support the time spent. Any activity performed from the list of examples given above should be documented.

Think about your documentation and what you are relating to someone who would be reviewing the medical record you created. Are you following the guidelines or are you following what your electronic health record is telling you the level of service should be? It will always be your documentation that will be needed to support the codes that are reported to the payer.

Congratulations to all for surviving the first year of significant changes to CPT E/M guidelines for office visits! Happy documenting through 2022!

If you have questions or suggestions for particular topics to cover in upcoming issues, please let us know at

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.

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