Covered and Noncovered Services : Evaluation and Management

Documentation

BadgerCare Plus and Wisconsin Medicaid have adopted the federal CMS 2021 and 2023 "Documentation Guidelines for Evaluation and Management Services," in combination with BadgerCare Plus and Medicaid policy for E&M services. Providers are required to present documentation upon request from the Wisconsin Department of Health Services indicating which of the guidelines or BadgerCare Plus policies were utilized for the E&M procedure code that was billed.

When using the CMS documentation guidelines for CPT procedure codes 99202–99205 and 99211–99215, providers are required to retain in their records whether they are billing using MDM or time. Based on CPT guidelines, if providers bill for time, total time must be reflected in the documentation.

The documentation in the member's medical record for each service must justify the level of the E&M code billed. Providers may access the CMS documentation guidelines on the CMS website. BadgerCare Plus and Medicaid policy information can be found in service-specific areas of the Online Handbook.

Documentation Requirements

Providers are required to meet the following documentation requirements for E&M services:

• The documentation must accurately reflect the services rendered and support the level of service submitted on the claim.
• Providers are required to document the E&M service at the time the service is provided or as soon as reasonably possible after the service is provided in order to maintain an accurate medical record. All documentation must be complete prior to submission of the claim. Before a service is reimbursed, the provider is required to meet all recordkeeping requirements, according to Wis. Stat. § 49.45(3)(f) and Wis. Admin. Code §§ DHS 106.02(9)(f) and 107.01.
• Providers should only consider medically relevant documentation in determining the appropriate procedure code to bill. The E&M level of service chosen by the provider should not be solely based on the amount of documentation recorded.

All providers who receive reimbursement from Wisconsin Medicaid are required to maintain records that fully document the basis of charges upon which all claims for payment are made, according to Wis. Admin. Code § DHS 106.02(9)(a).

ForwardHealth recognizes certain corrections or changes to a member's medical record when amended legally to accurately reflect the member's medical history. However, if these corrections or changes appear in the medical record following reimbursement determination, only the original medical record will be considered when determining if the reimbursement of services billed was appropriate.

No documentation iterations or section of iterations may be destroyed, deleted, whited-out or rendered illegible. When using a medical EHR or medical paper record, the provider must be able to generate an unadulterated audit trail that can verify the information and indicate which actions occurred, when they occurred, and by whom. The date, time, member identification, and user identification must be recorded when information within the record is created, modified, or accessed. Paper-based records must redact previous entries by putting a line through the notation and having it initialed and dated by the user.

Pre-Loaded Text for Electronic Health Records

When using EHR, it is acceptable for the provider to use pre-loaded text or other pre-generated text as long as the required personal documentation is in a secured (password-protected) system and the documentation reflects the actual service rendered. For any pre-loaded or other pre-generated text, the documentation must support that the provider verified the information as part of the professional service rendered.

Personal changes to the pre-loaded or pre-generated text made by the provider generally supports that the information has been verified as part of the professional service billed. Phrases that cannot be verified are not acceptable.

The EHR record must be signed by the renderer of the service.