CMS criteria for charting

This page was created to assist EM providers with meeting Medicaid and Medicare standards. The object is to distill down the CMS guidelines into easy to follow steps to meet standards for proper billing.

Background

CMS recognizes 5 levels of care including "critical care".

Levels 1-3 are routine charting (ie CC, HPI, ROS, PE, MDM.) typically levels 1-3 do not or require minimal testing/imaging or resuscitation efforts. Medical decision making tends to be straightforward or low complexity.

Levels 4-5 and critical care require more complex medical decision making (ie moderate-complex),imaging studies, serial labs and resuscitation.

Charting requirements.

Every chart requires a chief complaint.

• Example.jpg

  Caption1

• Example.jpg

  Caption2

Every chart requires a HPI w/ 4 of the eight descriptors listed here.

 -Location.

 -Quality.

 -Severity.

 -Duration.

 -Timing.

 -Context.

 -Modifying factors (alleviating vs aggravating).

 -Associated signs and symptoms. 

Review of Systems

 14 systems are recognized by CMS 

 Const.

 Eyes. 

 Ears,nose, mouth, throat. 
  
 CV.  
                      
 Respiratory. 
              
 GI.
                       
 GU.

 MSK. 

 Integument (skin and/or breasts).

 Neuro.

 Psych.

 Endo. 

 Hematological/Lymphatic.

 Allergic/Immunological.

 Lv 1-3 problem focused. Systems on pertinent to the complaint. 1-2 system review with one question per system. 

 Lv 4 2-9 systems with one question per system. 

 Lv5 10 or more systems with one or more question per system listed

"All other systems reviewed and were negative" is permissible. Concerns about this statement;

 -Assumes a full 14 system review.

 -Questionable if defendable in court.

 Concordance Between Electronic Clinical Documentation and Physicians’ Observed Behavior,   Berdahl, C., et al, JAMA Open, September 18, 2019

Past, Family, Social History (PFSH).

 Lv 1-4; at least one statement is required in order for CMS to consider the item documented.

 Lv5; requires two of the three mentioned to be documented. 

Physical Examination

 CMS recognizes 12 systems:

 Const.   
                   
 Eyes.  
                     
 Ears,nose, mouth, throat.  

 CV.  
                     
 Respiratory.
   
 GI. 
                     
 GU.

 MSK. 

 Integument (skin and/or breasts).

 Neuro.

 Psych.

 Hematological/Lymphatic.

 Requirements 

 Lv1-3. problem focused exam. 

 Lv4. 5-7 with a minimum of one element documented.

 Lv5. 8 or more with minimum one element documented. (a medicolegally defensible chart would     suggest a more comprehensive examination of relevant systems)

Medical decision making.

 Complexity matters. 

 4 types of medical decision making recognized.

 1. straightforward

 2. low complexity

 3. moderate complexity

 4. high complexity

For further guidance see MDM documentation and or Differential diagnosis documentation WikEM

References

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

Special Thanks to The Center for Emergency Medical Education (CEME) EM Boot. https://courses.ccme.org/course/embootcamp?gclid=Cj0KCQiAkNiMBhCxARIsAIDDKNVDk2xQgY-r8-28gaNGpRrhsd6QI3V3Np0AfEGLejLakpNtqfxY-z8aAvoTEALw_wcB