therapy to enroll in an appropriate clinical trial. (j) Physicians should respond compassionately when a patient who has undergone treatment abroad without the physician’s prior knowledge seeks nonemergent follow-up care. Those who are reluctant to provide such care should carefully consider: (i) the nature and duration of the patient-physician relationship; (ii) the likely impact on the individual patient’s well-being; (iii)the burden declining to provide follow-up care may impose on fellow professionals; (iv)the likely impact on the health and resources of the community. Physicians who are unable or unwilling to provide care in these circumstances have a responsibility to refer the patient to appropriate services.andomised, controlled, parallel-group, unmasked trial. Lancet. 2018;392:1047-1057. 27. Ticona L, This guide is intended to educate providers about the general principles of evaluation and management (E/M) documentation, common sets of codes used to bill for E/M services, and E/M services providers This guide is offered as a reference tool and does not replace content found in the 1995 Documentation Guidelines for Evaluation and Management Services and the 1997 Documentation Guidelines for Evaluation and Management Services. These publications are also available in the Reference Section. NOTE: For billing Medicare, you may use either version of the documentation guidelines for a patient encounter, not a combination of the two. For reporting services furnished on and after September 10, 2013, to Medicare, you may use the 1997 documentation guidelines for an extended history of present illness along with other elements from the 1995 documentation guidelines to document an evaluation and management service. Evaluation and Management Services Guide MLN Booklet Page 4 of 23 MLN006764 February 2021 GENERAL PRINCIPLES OF E/M DOCUMENTATION Clear and concise medical record documentation is critical to providing patients with quality care and is required for you to receive accurate and timely payment for furnished services. Medical records chronologically report the care a patient received and record pertinent facts, findings, and observations about the patient’s health history. Medical record documentation helps physicians and other health care professionals evaluate and plan the patient’s immediate treatment and monitor the patient’s health care over time. Health care payers may require reasonable documentation to ensure that a service is consistent with the patient’s insurance coverage and to validate: ● The site of service ● The medical necessity and appropriateness of the diagnostic and/or therapeutic services provided ● That services furnished were accurately reported General principles of medical record documentation apply to all types of medical and surgical services in all settings. While E/M services vary in several ways, such as the nature and amount of physician work required, these general principles help ensure that medical record documentation for all E/M services is appropriate: ● The medical record should be complete and legible ● The documentation of each patient encounter should include: • Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results • Assessment, clinical impression, or diagnosis • Medical plan of care ● If date and legible identity of the observer if the rationale for ordering diagnostic and other ancillary services is not documented, it should be easily inferred ● Past and present diagnoses should be accessible to the treating and/or consulting physician ● Appropriate health risk factors should be identified ● The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented ● The diagnosis and treatment codes reported on the health insurance claim form or billing statement should be supported by documentation in the medical record To maintain an accurate medical record, document services during the encounter or as soon as practicable after the encounter. Page 5 of 23 MLN006764 February 2021 Evaluation and Management Services Guide MLN Booklet COMMON SETS OF CODES USED TO BILL FOR E/M SERVICES When billing for a patient’s visit, select codes that best represent the services furnished during the visit. A billing specialist or alternate source may review the provider’s documented services before submitting the claim to a payer. These reviewers help select codes that best reflect the provider’s furnished services. However, the provider must ensure that the submitted claim accurately reflects the services provided. The provider must also ensure that medical record documentation supports the level of service reported to a payer. You should not use the volume of documentation to determine which specific level of service to bill. Services must meet specific medical necessity requirements in the statute, regulations, and manuals and specific medical necessity criteria defined by National Coverage Determinations and Local Coverage Determinations (if any exist for the service reported on the claim). For every service billed, you must indicate the specific sign, symptom, or patient complaint that makes the service reasonable and necessary. HCPCS The HCPCS is the Health Insurance Portability and Accountability Act-compliant