Correct Use of the Checklist in Evaluation and Management Documentation
In this era of needing to ensure services are accurately and thoroughly documented, there is a growing use of templates and/or checklists used by providers. Providers appreciate these helpful tools and aids because checklists help save time.
Examination templates and checklists are considered acceptable documentation. However, when using them they need to be used correctly. When a service is not documented properly on a checklist, medical necessity is unsubstantiated and the level of E & M service billed will be denied or downcoded.
What is the proper use of a checklist as it relates to an E & M visit? Keep the following important documentation guidelines in mind when using a template and/or checklist:
- Examination templates and checklists are acceptable documentation provided the provider has clearly indicated what was examined and the findings to support the level of service billed.
- A brief statement or notation indicating "negative" or "normal" is sufficient to document normal findings.
- Abnormal or unexpected findings of the examination of the unaffected or asymptomatic body area(s) or organ system(s) must be described.
- The provider must document and describe any specific and pertinent abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s). A notation of "abnormal" without elaboration is insufficient documentation.
- A key explaining checklist symbols may be submitted, if helpful to the Medicare contractor and must be available, if requested.
- Signature requirements remain the same in the use of checklists. Per NCP PHYS-001,"an indication of a signature in some form needs to be present." Documentation must support legible identification of the billing provider, per the 1995 and 1997 Evaluation and Management Documentation Guidelines.
- The Review of Systems (ROS) and Past Family Social History (PFSH) may be recorded by ancillary staff or completed by the patient, on a form or checklist. The checklist must have a place for the physician to document that he/she reviewed the information. The physician should make a notation supplementing or confirming the information recorded by others.
- If the ROS and/or PFSH are unchanged from an earlier encounter, it does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may be documented by noting the date and location of the earlier ROS and/or PFSH with a description of any new findings and/or a statement that all other elements are unchanged.
- When referring to an earlier encounter to document the ROS and/or PFSH, all elements documented and performed in the earlier visit must be reviewed in the current visit. Any variation or elements not reviewed must be documented in the current note.
Important Reminder: only the provider can perform the History of Present Illness (HPI).
In conclusion, the provider is ultimately responsible for submitting appropriate documentation. Each item on a checklist requires an active response for each exam component performed or question asked. It is not appropriate to use a common template which states that all components listed were performed unless otherwise noted by the physician.
Resources:
NCP, PHYS-001, General Coverage for Physicians' Services
Medicare Part B Seminars/Provider Outreach Department
Medicare Resident & New Physician Guide, Chapter 6, Evaluation and Management Documentation
