Evaluation & Management Documentation

March 2014

Effective with dates of service beginning May 1, 2014, WSI will adopt the guidelines highlighted below in the auditing of Evaluation and Management (E/M) documentation.

History Section

  • History of Present Illness: If applicable, documentation must identify the chronic conditions; stating three chronic conditions is not sufficient.
  • Review of Systems: A descriptive response is required for any system with a positive or pertinent negative response; stating negative, un-remarkable, non-remarkable, or noncontributory is not sufficient for pertinent negative responses.
  • Past Family Social History: A descriptive response is required for PFSH; stating not on file, noncontributory, negative is not sufficient.

Exam Section

  • A description response is required for abnormal and pertinent negative findings; stating abnormal, negative, un-remarkable, non-remarkable or noncontributory is not sufficient.

The E/M Documentation Guidelines outlines all of the necessary elements of documentation used in the auditing of bills.

If you have questions about this article, please send an email to wsipr@nd.gov.