When selecting a type of history what four main types of information should the coder review?

Evaluation and Management (E&M) Service – E&M services are performed by physicians and non physician practitioners (NPPs).  The level of E&M is selected using the patient type (new or established patient), the setting of service and the level of E&M performed.  E&M services include office and other outpatient services, hospital observation services, hospital inpatient services, consultations, emergency department services, nursing facility services, domiciliary care services, and home services.

New patient – is an individual who has not received any professional services from the physician/non-physician practitioner (NPP) or another physician/NPP of the same specialty who belongs to the same group practice within the previous three years.

Established patient – an individual who has received professional services from the physician/NPP or another physician/NPP of the same specialty who belongs to the same group practice within the previous three years.

STANDARD

E&M services contain three “key” components, history, examination and medical decision making, which are used as a basis for selecting a level of E&M service.  Each of these three components have different levels of complexity.  Selection of the appropriate level of complexity and appropriate selection of the level of service must be reflected in the medical record documentation.

The documentation of these three components (history, examination and medical decision making) depends on clinical judgment of the provider and the nature of the presenting problem(s).

The level of service is determined by using a combination of the levels of complexity for each of the 3 key components and medical necessity.  Medical necessity is the overarching criterion for determining the level of service.  It would not be medically necessary or appropriate to bill a higher level of E&M service when a lower level of service is warranted.

A.  History

The history is comprised of a chief complaint, the history of present illness (HPI) or the status of three chronic conditions, the review of systems (ROS) and past, family, social history (PFSH).

• Chief Complaint
  • The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis,  physicians recommended return, or other factor that is the reason for the encounter.

• History of Present Illness (HPI)
  • The HPI is a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present.  It includes the following elements:
    • location,
    • quality,
    • severity,
    • duration,
    • timing,
    • context,
    • modifying factors, and
    • associated signs and symptoms.
  • Levels of Complexity
    • Brief – One to three HPI elements
    • Extended – Four or more HPI elements
• Status of at least three chronic or inactive conditions
  • Documenting the status of three chronic or inactive conditions is an alternative to documenting HPI elements.  This is permissible with both 1995 and 1997 Examination Documentation Guidelines.
  • Levels of Complexity
    • Extended – status of three chronic or inactive conditions
• Review of Systems (ROS)
  • A ROS is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced.  For purposes of ROS, the following systems are recognized:
    • Constitutional symptoms (e.g., fever, weight loss)
    • Eyes
    • Ears, Nose, Mouth, Throat
    • Cardiovascular
    • Respiratory
    • Gastrointestinal
    • Genitourinary
    • Musculoskeletal
    • Integumentary (skin and/or breast)
    • Neurological
    • Psychiatric
    • Endocrine
    • Hematologic/Lymphatic
    • Allergic/Immunologic
  • Levels of Complexity
    • Problem Pertinent – 1 ROS
    • Extended – 2-9 ROS
    • Complete – At least 10 ROS
• Past, Family, Social History (PFSH)
  • The PFSH consists of a review of three areas:
    • past history (the patient’s past experiences with illnesses, operations, injuries and treatments);
    • family history (a review of medical events in the patient’s family, including diseases which may be hereditary or place the patient at risk); and
    • social history (an age appropriate review of past and current activities).
  • For the categories of subsequent hospital care, follow-up inpatient consultations and subsequent nursing facility care, CPT requires only an “interval” history.  It is not necessary to record information about the PFSH.
  • Levels of Complexity
    • Pertinent – One item from any of the three history areas
    • Complete:
      • At least one item from two of the three history areas for office or other outpatient services established patient, emergency department, subsequent nursing facility care, domiciliary care established patient, and home care established patient.
      • At least one item from each of the three history areas for office or other outpatient services new patient, hospital observation services, hospital inpatient services initial care, consultations, comprehensive nursing facility assessments, domiciliary care new patient and home care, new patient.

There are four levels of complexity of history; problem focused, expanded problem focused, detailed and comprehensive.  The level of history is based upon documentation of the chief complaint, HPI, ROS and PFSH found in the medical record.

• Problem Focused – requires documentation of a chief complaint and a brief history of present illness (HPI).
• Expanded Problem Focused – requires documentation of a chief complaint, a brief history of present illness (HPI) and a problem pertinent review of systems (ROS).
• Detailed – requires documentation of a chief complaint, an extended history of present illness (HPI) an extended review of systems (ROS) and a pertinent past, family, and/or social history (PFSH).
• Comprehensive – requires documentation of a chief complaint, an extended history of present illness (HPI), a complete review of systems (ROS) and complete past, family and social history (PFSH).

History Documentation Guidelines

• A review of systems (ROS) or a past, family, social history (PFSH) from a previous encounter does not have to be re-recorded as long as the physician indicates that he reviewed and updated this information.  To indicate this, the physician may describe a new ROS or PFSH, note there are no changes from previous ROS and PFSH and note the date and location of the previous ROS/PFSH referred to in the present note.
• If the PFSH and/or ROS was recorded by ancillary staff (including residents) or a form was completed by the patient, the physician must document that he reviewed, confirmed and/or supplemented the information.
• If the physician is unable to obtain a history from the patient, family or other source, the documentation should describe the patient’s condition and other circumstances that preclude not being able to obtain a history.
• A complete review of systems may be documented by either listing each system individually or by documenting the pertinent positive and negative systems and then making a notation of “all other systems are negative”.

B.  Examination

There are two types of examinations that can be used to determine the level of exam; 1995 and 1997 Evaluation and Management (E/M) Documentation Guidelines.  Providers may use whichever exam is most beneficial to them.

• 1995 E/M Documentation Guidelines (See the attached 1995 E & M Guidelines)
  • The 1995 exam is composed of body areas and organ systems
    • Body Areas:
      • Head, including the face
      • Neck
      • Chest, including breasts and axillae
      • Abdomen
      • Genitalia, groin, buttocks
      • Back, including spine
      • Each extremity
    • Organ Systems:
      • Constitutional (e.g., vital signs, general appearance)
      • Eyes
      • Ears, nose, mouth and throat
      • Cardiovascular
      • Respiratory
      • Gastrointestinal
      • Genitourinary
      • Musculoskeletal
      • Skin
      • Neurologic
      • Psychiatric
      • Hematologic/lymphatic/immunologic
    • Levels of Complexity – There are four levels of complexity of the 1995 Examination.  The level of exam is based upon documentation.
      • Problem Focused — a limited examination of the affected body area or organ system.
      • Expanded Problem Focused — a limited examination of the affected body area or organ system and other symptomatic or related organ systems.
      • Detailed — an extended examination of the affected body area(s) and other symptomatic or related organ system(s).
      • Comprehensive — a general multi-system examination or a complete examination of a single organ system.  The medical record for a general multi-system examination should include findings of 8 or more organ systems.

• 1995 Documentation Guidelines
  • Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented.  A notation of “abnormal” without elaboration is insufficient.
  • Abnormal or unexpected findings of the examination of the unaffected or asymptomatic body area(s) or organ system(s) should be described.
  • A brief statement or notation indicating “negative” or “normal” is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s).

• 1997 E/M Documentation Guidelines (See the attached 1997 E & M Guidelines)
  • There are two types of examinations defined in the 1997 E/M Exam; General multi-system exam and Single Organ System Exam.  A general multi-system examination or a single organ system examination may be performed by any physician regardless of specialty.  The type (general multi-system or single organ system) and content of examination are selected by the examining physician and are based upon clinical judgment, the patient’s history, and the nature of the presenting problem(s).
    • The General Multi-system Exam is composed of body areas and organ systems that contain specific elements to be examined and documented.  Each element is identified by a bullet.
    • Levels of Complexity-General multi-system exam
      • Problem Focused – Performance and documentation of one to five elements identified by a bullet.
      • Expanded Problem Focused – Performance and documentation of at least six elements identified by a bullet.
      • Detailed – Performance and documentation of at least two elements identified by a bullet from each of six areas/systems OR at least twelve elements identified by a bullet in two or more areas/systems.
      • Comprehensive – Perform all elements identified by a bullet in at least nine organ systems or body areas and document at least two elements identified by a bullet from each of nine areas/systems.
    • Single System Organ Exams – is composed of body areas and organ systems specific to a single organ; each exam element is identified by a bullet.
      • Cardiovascular
      • Ears, Nose, Mouth and Throat
      • Eyes
      • Genitourinary (Female)
      • Genitourinary (Male)
      • Hematologic/Lymphatic/Immunologic
      • Musculoskeletal
      • Neurological
      • Psychiatric
      • Respiratory
      • Skin
    • Levels of Complexity – There are four levels of complexity of the 1997 Examination.  The level of exam is based upon documentation.
      • Problem Focused Examination — should include performance and documentation of one to five elements identified by a bullet (•), whether in a box with a shaded or unshaded border.
      • Expanded Problem Focused Examination — should include performance and documentation of at least six elements identified by a bullet (•), whether in a box with a shaded or unshaded border.
      • Detailed Examination — examinations other than the eye and psychiatric examinations should include performance and documentation of at least twelve elements identified by a bullet (•), whether in box with a shaded or unshaded border.
        • *Eye and psychiatric examinations should include the performance and documentation of at least nine elements identified by a bullet (•), whether in a box with a shaded or unshaded border.
      • Comprehensive Examination — should include performance of all elements identified by a bullet (•), whether in a shaded or unshaded box.  Documentation of every element in each box with a shaded border and at least one element in each box with an unshaded border is expected.
      • *Elements in a shaded or unshaded border is further defined in the attached 1997 E & M Guidelines
• 1997 Exam Documentation Guidelines
  • Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. A notation of “abnormal” without elaboration is insufficient.
  • Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or organ system(s) should be described.
  • A brief statement or notation indicating “negative” or “normal” is sufficient to document normal findings.

C.  Medical Decision Making

Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:

• The number of possible diagnoses and/or the number of management options that must be considered.
  • The number of diagnoses is based on the number and types of problems (new or established, stable or worsening) documented in the medical record.
• The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed.
  • Diagnostic testing ordered or reviewed
  • A decision to obtain and review old medical records
  • Obtain history from sources other than the patient
  • Discussion of contradictory or unexpected test results with the physician who performed or interpreted the test
  • The ordering physician may personally review a image, tracing or specimen
• The risk of significant complications, morbidity and/or mortality, as well as co morbidities, associated with the patient’s presenting problem(s), the diagnostic procedure(s) and/or the possible management options.
  • See the Table of Risk in the 1995 or 1997 E/M Documentation Guidelines.  The highest level of risk in any one category (presenting problem(s), diagnostic procedure(s), or management options) determines the overall risk.
• Levels of Complexity
  • Straightforward — involves a minimal number of diagnoses or treatment options, minimal amount of data to be reviewed and a minimal risk of morbidity or mortality (M&M).
  • Low Complexity — involves a limited number of diagnoses, limited amount of data to be reviewed and a low risk of M&M.
  • Moderate Complexity — multiple numbers of diagnosis or treatment options, moderate amount of data to be reviewed and a moderate risk of M&M.
  • Extensive — extensive number of diagnosis and treatment options, extensive amount of data to be reviewed and a high risk of M&M.

REGULATORY REFERENCES

Evaluation and Management Services Guide. Medicare Learning Network. December 2010.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network

1995 DOCUMENTATION GUIDELINES FOR EVALUATION & MANAGEMENT SERVICES

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf

1997 DOCUMENTATION GUIDELINES FOR EVALUATION AND MANAGEMENT SERVICES

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf

CMS Claims Processing Manual 100-04, Ch. 12, 30.6 Evaluation and Management Codes-General.

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf

QUESTIONS

Questions regarding policies, procedures or interpretations should be directed to the USC Office of Culture, Ethics and Compliance at (323) 442-8588 or USC Help & Reporting Line at (213) 740-2500 or (800) 348-7454.

When selecting a type of history what 4 main types of information should the coder review?

What are the four elements of history in CPT coding?

What are the 4 levels of history?

When selecting a type of history the coder should review the chief complaint history of the presenting illness review of systems and past family and social history?