Evaluation and Management Questions & Answers - History
For the purpose of this document, the term physician means the individual billing entity including both physicians and non-physician practitioners billing under his/her National Provider Identifier (NPI).
History
Q 1. Where does it state that ancillary staff can record the chief complaint (CC)? In addition, can you confirm that ancillary staff can obtain the review of systems (ROS) and past, family and social history (PFSH?)
A 1. The 1995 and 1997 Documentation Guidelines (DG) do not address who can record the chief complaint. WPS Medicare will allow the CC when recorded by ancillary staff. However, the physician must validate the CC in the documentation. The 1995 and the 1997 Documentation guidelines indicate ancillary staff may obtain the ROS and PFSH but they do not indicate the ancillary staff can obtain the History of Present illness.
Q 2. Where does it state that if the history is unobtainable you cannot automatically bill a comprehensive history? Do you automatically have to bill based on a problem-focused history?
A 2. There is nothing notated in the 1995 or 1997 DG to indicate any level of history is automatic. The physician should document the reason the patient is unable to provide history and document his/her efforts to obtain history from other sources. This could include family members, other medical personnel, obtaining old medical records (if available) and using information contained therein to document some of the history components (past medical, family, social).
Q 3. We are unable to obtain history as the patient is intubated. Do we have to bill a Not Otherwise Classified (NOC) code?
A 3. You would only submit a NOC code when you are unable to document any of the history elements. If you are talking to the patient's family or others to obtain history, document the work performed and code based on the work performed.
Q 4. We received information that the Centers for Medicare & Medicaid Services (CMS) no longer recognizes "all other systems negative" when documenting a complete Review of Systems (ROS).
A 4. The 1995 and 1997 DG indicate, "a complete ROS inquires about the system(s) directly related to the problem(s) indentified in the HPI plus all additional body systems." The DG also state, "At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented." We do not find any additional published information from CMS.
Q 5. When a patient presents at the office for ongoing monitoring/evaluation of a condition such as diabetes or hypertension is location inferred, given there is no specific anatomical location for these disease processes?
A 5. Location refers to the History of Present Illness (HPI). The 1995 and 1997 DG include the definition of brief and extended HPI. The DG does not indicate a physician may infer location. Choose a brief or extended HPI based on the documentation.
Q 6. Can a physician count a single history item in both the HPI and ROS? For example, could we count "shortness of breath" as an associated sign and symptom in the HPI and respiratory system in the ROS?
A 6. A clearly documented medical record would prevent the need to "double-dip" for HPI and ROS, but WPS Medicare, in rare circumstances, could accept counting one statement in both areas if necessary.
Q 7. Where can I get CMS' documentation stating three chronic or inactive conditions apply to both 95 and 97 guidelines?
A 7. The 1997 DG state an extended HPI consists of at least four elements of the HPI or the status of at least three chronic or inactive conditions. The 1995 DG do not have this statement. However, WPS Medicare received clarification from CMS indicating this statement applies to both 1995 and 1997.
Q 8. When documenting three chronic or inactive conditions, do I have to do more than mention the conditions?
A 8. The documentation should show what actions the physician is taking concerning these conditions and how they affect the chief complaint.
Q 9. Is chief complaint required for interval history in a nursing home?
A 9. The chief complaint is the reason for the visit. Documentation for all E/M must include the chief complaint.
Q 10. Is it necessary to document all three components (History, Exam, and Medical Decision Making) for an established patient visit to bill an E/M 99211 - 99215 visit or must you bill 99499 if only two are documented. Keeping in mind, only two are required for established patients.
A 10. Our response to this question during recent a recent teleconference and multiple seminars was all three elements were required, but only two were used in choosing a procedure code. In response to questions from the physician community, we took this question to CMS. The 1995 and 1997 DG provide general principles of medical record documentation which states: "The principles of documentation listed below are applicable to all types of medical and surgical services in all settings. For E/M services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient's status. The general principles listed below may be modified to account for these variable circumstances in providing E/M services." The information then goes on to state in part:
"The documentation of each patient encounter should include:
i. Reason for the encounter and relevant history, physician examination findings, and prior diagnostic test results
ii. Assessment, clinical impressions, or diagnosis
iii. Medical plan of care
iv. Date and legible identity of the observer. "
Q 11. Can the physician carry forward a chronic problem in his/her documentation for an inpatient visit?
A 11. The procedure codes for subsequent hospital visits require an interval history. An interval history is an update to the previous history taken.
Q 12. If the documentation states the patient is adopted, is that sufficient for the family history?
A 12. Yes.
Q 13. When talking about an extended HPI (four or more elements or the status of at least three chronic conditions), do the elements or the chronic conditions have to have a bearing on the chief complaint for that encounter?
A 13. Yes. The documentation should show what actions the physician is taking concerning these conditions and how they affect the chief complaint.
Q 14. When using an electronic medical record, do you have to notate in the documentation for today's encounter where the ROS and PFSH are stored?
A 14. When responding to a request for documentation from WPS Medicare or other entity, you would need to supply documentation to support the service billed, including any previously recorded information. You will need to know where the previous information is stored.
Q 15. Can an allergy be part of the ROS rather than the past history? For example, patient has allergy to penicillin; it causes hives?
A 15. Yes.
Q 16. Can the medical assistant (MA) document the chief complaint? There may be some rare instances where the MA documents "F/U for HTN" and the physician then documents the exam and medical decision-making. Can we code this as a visit or must we use the NOC 99499?
A 16. There is no restriction on a medical assistant documenting the chief complaint. However, the physician must validate the CC in the documentation.
Q 17. This question pertains to an Electronic Medical Record (EMR.) We have always been taught that the progress note "stands alone." When we are auditing physician's notes to determine if they are billing the appropriate level of service, what parts of the EMR can be used toward their levels without requiring them to reference it? We are referring specially to Growth charts, Past, Family, & Social History, Medication Listings, Allergies, etc.
A 17. If the physician were not referencing previous material in the EMR, then the information would not be used in choosing the level of E/M service.
Q 18. If the past medical section states a chronic or current illness (that the physician is not treating), can it be used in the Review of Systems (ROS)? If the past medical section lists several conditions and there is no mention of controlled or uncontrolled, could this be used in the ROS?
A 18. A. No, per both the 1995 and 1997 E/M DG, "A Review of Systems is an inventory of body systems obtained through a series of questions seeking to identify signs or symptoms that the patient may be experiencing or has experienced." A past medical history would not contain a patient's pertinent positive and/or negative response as related to the problems identified in the patient's history of the present illness.
Q 19. Who can perform the History of Present Illness (HPI) portion of the patient's history?
A 19. The history portion refers to the subjective information obtained by the physician or ancillary staff. Although ancillary staff can perform the other parts of the history, that staff cannot perform the HPI. Only the physician can perform the HPI.
Q 20. Can the status of a chronic or inactive disease be used in the HPI in lieu of a new problem or illness?
A 20. Yes, the HPI would then show the changes since the last encounter.
Q 21. If the nurse takes the HPI, can the physician then state, "HPI as above by the nurse" or just "HPI as above in the documentation"?
A 21. No. The physician billing the service must document the HPI.
Q 22. Can the History of Present Illness (HPI) elements be counted for both the Chief Complaint (CC) and the associated signs/symptoms? For instance, a patient presents with chest (location) pain (CC) that she has had for 3 days (duration). She also experiences shortness of breath (associated signs/symptoms) when walking up the stairs (context).
A 22. Yes. According to the E/M 1995 and 1997 DG, "The CC, ROS, and PFSH may be listed as separate elements of history or they may be included in the description of the history of present illness
Q 23. How is context for HPI elements defined?
A 23. Context is the circumstances or factors that surround a particular event, including what precedes or follows a symptom. For example, a physician may see a patient who experiences esophageal reflux that occurs most nights approximately 2 hours after he goes to bed and if he has had supper after 8 p.m. If the patient sleeps with his head elevated, he has symptoms on fewer nights.
In this scenario, when the esophageal reflux happens (at night), the circumstances under which the esophageal reflux happens (eating after 8 p.m.) and what makes the esophageal reflux better (head elevated) would constitute "context."
Page Last Updated: Thursday, 18-Mar-2010 05:56:43 CDT
