The old standby still works like a charm to show medical necessity.
The American Medical Association’s (AMA’s) 2021 Evaluation and Management Services Guidelines (2021 E/M guidelines) are the biggest change in medical coding since the creation of the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services by the Centers for Medicare & Medicaid Services (CMS). There have been many formats for documenting the patient encounter since then. Subjective, objective, assessment, and plan (SOAP) documentation has been a standard for nearly 50 years, and for good reason: SOAP allows clinicians to clearly document patient care and treatment.
New Isn’t Always Improved
Templated information has become the standard for documenting the patient encounter in electronic health records (EHRs) as a result of the 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act and the push for EHR interoperability. Templated information holds both good and perhaps not so good qualities, however, such as copy/paste, carry forward, and cookie-cutter documentation.
This lackluster documentation won’t hold up with the new E/M guidelines. According to the 2021 E/M guidelines, “Office or other outpatient services include a medically appropriate history and/or physical examination, when performed. … The extent of history and physical examination is not an element in selection of the level of office or other outpatient codes.”
Gone are the days of counting bullets and elements of history of present illness (HPI), review of systems (ROS), past medical, family, and social history (PFSH), and exam, at least for this category of codes. Documentation should now include what the provider feels is relevant and will help to support medical necessity of the encounter. Providers may find reverting back to SOAP to document 2021 office and other outpatient E/M services (CPT® 99202-99215) more helpful in their quest to show medical necessity for services rendered.
Case in Point
Let’s compare documentation of an encounter to that of a book:
- The chief complaint is the title of today’s encounter.
- The history sets the stage for the encounter.
- The exam expands upon today’s story.
- The assessment summarizes what our story brought to light.
- The plan closes the story.
A deeper look at SOAP may assist providers in how to document the encounter (story).
This element describes the patient’s statements about their symptoms and current condition(s). The elements of HPI work very well for this:
Location – Where the condition is located.
Duration – How long the condition has been occurring.
Severity – The severity of the problem on a scale of 1 to 10.
Quality – Description of condition such as aching, burning, radiating pain.
Context – Circumstances when the issue was first noticed; how the problem has manifested since onset.
Modifying factors – Things that have been tried and have an impact on the condition.
Timing – The status of the problem (constant, comes and goes).
Associated signs/symptoms – Other conditions that may be occurring alongside the presenting problem.
Mrs. Smith presents today with a two-week history of left knee pain. She indicates that she has been told she has bone-on-bone osteoarthritis. She has tried cortisone injections in the past without relief. She presents to our clinic today as a new patient inquiring about other treatment options. She does share that she had been climbing stairs more frequently while she was visiting family and that her knee has become swollen and painful.
The HPI adds rich details that can help to support medical necessity. The other elements of history, such as ROS and PFSH, can be documented at the provider’s discretion.
This section contains information that is measurable and quantitative. Information in this section includes:
- Vital signs
- Physical examination findings
- Laboratory data
- Imaging results
- Other diagnostic data
- Review of other pertinent documentation
Vital signs recorded for today’s visit: BP 120/76, height 5’6”, weight 125 pounds, pulse 72 bpm. Upon examination, Mrs. Smith’s mobility is evaluated on left vs. right leg. The range of motion on the left leg is diminished in comparison to that on the right side. She does not have decreased sensation or pulses in either lower extremity. Her left knee is visibly swollen and painful. I have reviewed her previous X-rays from last year that she had sent to us and there is obvious decrease in the joint space on the left knee. We will get X-rays today to compare to those.
This objective information is specific to the presenting problem and includes only elements the provider deems necessary.
The assessment is a compilation of information from subjective and objective that is used to arrive at a diagnosis. Elements that may be included in the assessment are:
Problem – A list of problem(s) in order of importance (diagnosis).
Differential diagnosis – The possible problems from most to least likely, including the thought process behind them. This should include other possible diagnoses.
After reviewing and comparing the X-rays of the left knee, it is apparent that the joint space is bone-on-bone. We have discussed the possible options for treatment of osteoarthritis in the left knee that include another cortisone injection, gel injection, PRP injection, and surgical intervention.
This assessment includes information on possible treatment options. It could also include any contraindications specific to this patient, as well as any discussion.
Any good book has a conclusion and that is what the plan tells in this story. The plan can include:
- Testing that will be performed along with the rationale and next steps if the testing is positive or negative.
- Therapy needed, including medications. Documentation of changes in dosage of existing medications.
- The frequency the patient is to be seen in follow-up. This sometimes is a hint at the severity of the problem; a patient not returning for a year likely has a less complex condition than one who is seen frequently. This could indicate the condition is stable.
After reviewing the different treatment options, Mrs. Smith would like to pursue the gel injection, considering the limited relief of the last couple steroid injections. I have explained that insurance may not cover this, so we would like to verify benefits before proceeding. We should be able to determine her coverage in the next week. In the meantime, we have prescribed Meloxicam 7.5 mg once a day and have counseled her not to take additional ibuprofen with it. She may take acetaminophen to supplement for the joint pain. We will contact her after we have verified coverage and set up the injection appointment.
This plan gives us a closure to the story: A new prescription was given for the presenting problem and the patient will return soon for an injection.
Ensure Quality Outcomes
SOAP documentation can aid in telling an accurate story of the patient’s encounter. It is important to remember that medical documentation serves multiple purposes in addition to an accurate accounting of the patient’s health, including legal protection and reimbursement. The SOAP format aids in organizing a patient’s information into a succinct and thorough note that ultimately promotes quality of care.
Vivek Podder; Valerie Lew; Sassan Ghassemzadeh, “SOAP Notes,” Last update: Sept. 3, 2020. https://www.ncbi.nlm.nih.gov/books/NBK482263
AMA, 2021 Evaluation and Management Guidelines, page 4, History and/or Examination, updated 3/9/2021. https://www.ama-assn.org/system/files/2019-06/cpt-office-prolonged-svs-code-changes.pdf