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.

-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;

1.Assumes a full 14 system review.

2. Questionable if defendable in court. (Concordance Between Electronic Clinical Documentation and Physicians’ Observed Behavior, Berdahl, C., et al, JAMA Open, September 18, 2019)

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2751388

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

Number of diagnoses or management options	Amount and/or complexity of data to be reviewed	Risk of complications and/or morbidity or mortality	Type of decision making
Minimal	Minimal/none	Minimal	Straight forward
Limited	Limited	Low	Low Complexity
Multiple	Moderate	Moderate	Moderate Complexity
Extensive	Extensive	High	High Complexity	CMS Example of MDM “Multiple possible diagnoses for patient’s chest pain considered. After reviewing the patient’s medical record, lab and radiology results and discussing the case with the patient’s PMD, doubt PE as pulse oximetry normal and no tachypnea or tachycardia. Dissection unlikely as presentation not consistent with the diagnosis. ACS unlikely as normal EKG and no risk factors. Combination of infiltrate on CXR, fever and cough make pneumonia most likely diagnosis. Moderate risk of complications. Will treat with antibiotics and admit.” 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