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http://supercoder.com ; What Medical Documentation Guidelines Are You Missing? If you are in the medical coding profession this is a must see presentation.You’re ready to do your quarterly in practice chart auditing; Make sure you’ve got your history requirements nailed down to get the evaluation and management code levels your physicians deserve.You could be under coding your services if you - or your physicians - are miscounting History of Present Illness (HPI), Past Medical Family Social History (PMFSH), or Review of Systems (ROS). Alternatively, auditors will be looking for specific documentation to support your E&M coding - or you’ll be facing paybacks. * Decrease your practice’s compliance risk using easy to use history of present illness (HPI) guide. * Stop shorting yourself E&M coding levels with this most often overlooked medical coding history type. * How much review of systems (ROS) documentation is enough? * Obtain accurate E&M coding by identifying all HPI elements. * Using an Electronic Health Record (EHR)? Do this to support your evaluation and management code. * Avoid fraud charges by adhering to who the AMA says must provide HPI.If you would like to view the recorded webinar pressentation visit us at www.facebook.com/supercoderpage!
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History of Present IllnessHistory of Present Illness
Jen Godreau, BA, CPC, CPEDCContent Director
Inhealthcare’s [email protected]
March 9, 2010
www.supercoder.com
Four parts of a History
Chief Complaint (CC)
History of Present Illness (HPI)
Past Medical Family Social History (PMFSH)
Review of Systems (ROS).
Example:99202: A level 2 new patient office visit requires
an expanded problem-focused history. An expanded problem focused history requires:
Type CPT Medicare
CC Required for sick Required for sick
HPI Brief 1-3 element/s
ROS Problem Pertinent 1 system
PFSH Not required
8 Areas That Help Determine HPI
8 Areas That Help Determine HPI
QualityRepresents the chief complaint
or signs or symptoms
TimingThe time of day the patient
experienced the signs and symptoms
8 Areas That Help Determine HPI
SeverityJust how serious is the
patient‘s condition?
DurationHow long have the
patient's signs and symptoms been present?
8 Areas That Help Determine HPI
Modifying FactorsWhat the patient did to
alleviate pain or exacerbate
Associated signs and symptoms
Are any other problems the patient has in addition to the chief complaint?
HPI Element Principles1997 EM Guidelines allow you to count the
status of chronic conditions • 1-2 chronic conditions counts as a brief HPI; 3
or more is an extended HPI
Physician must obtain and document the HPI• must indicate his actual review and interaction
Guidelines have never defined if staff are allowed to document the history of present illness
Ancillary staff does not have permission to collect the HPI
Ancillary staff can collect ROS and PFSH
E/M service code values include physician work for performing the HPI.
No double dipping. You get credit for any given HPI element only onceIn a note that indicates:
“dull, aching back pain,”
Dull +Aching 1 quality
Let’s try it!Est patient here today for sore throat (location) and
productive cough (associated signs and symptoms). Throat hurts worst at night (timing) and is a 7 (severity)
Solution?The physician documented four elements in
the note. Four elements counts as an extended HPI. For an established patient visit, an extended HPI supports a level greater than or equal to 99214. For a new patient visit code, extended HPI supports an E/M level greater than or equal to 99203 provided the visit meets all other required elements as well.
What Is ROS?Physician reviews systems directly related
to the problem or problems identified in the HPI portion of the E/M and a number of additional systems.
CPT defines ROS as: “an inventory of body systems obtained
through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced.”
ROS “helps define the problem, clarify the differential diagnosis, identify needed testing, or serves as baseline data on other systems that might be affected by any possible management options.”
Example: A patient reports to the FP complaining of a
headache. The FP inquires about how long the headache has lasted, and a few other questions to rule out migraines.
The FP discovers that the patient has not taken any medication for the headaches, he prescribes several over-the-counter options to deal with the condition, and tells the patient to come back in for another exam if the headaches worsen or increase in frequency. In this instance, you can only consider 1 system reviewed (neurological), since the FP
has apparently only inquired about the system directly related to the problem.
Count These SystemsCPT identifies the following ROS
elements
What Are the Different ROS Levels?
Problem-pertinent: When the physician reviews one system, you have a problem-pertinent ROS. This ROS level can support up to a level-two
new patient E/M (99202, an expanded problem-focused history; an
expanded problem-focused examination; and straightforward medical decision making) or a level-three established patient service (99213, … an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity).
What Are the Different ROS Levels?
Extended: When the physician reviews two to nine systems, the encounter is an extended ROS.Extended ROS can support up to a level-three
new patient service (99203, … a detailed history; a detailed
examination; and medical decision-making of low complexity) or level-four established patient service (99214, … a detailed history; a detailed examination; medical decision-making of moderate complexity).
What Are the Different ROS Levels?Complete: For a complete ROS, most insurers accept
a review of 10 or more systems with all others documented. Per CPT, a complete ROS requires a review of all additional body systems. This would include 14 systems. The CMS Documentation Guidelines define a complete ROS as covering at least 10 organ systems. “A complete ROS inquires about the system(s) directly related
to the problem(s) identified in the HPI plus all additional body systems,” the E/M Documentation Guidelines state.
With a complete ROS, reporting a 99204, 99205 or is possible -- depending on other encounter specifics.
Example: An internist sees a patient with multiple chronic
conditions: COPD, CHF, hypertension, and diabetes. The physician asks questions about 10 of the systems, including constitutional, eyes, cardiovascular, respiratory, integumentary, neurological, and endocrine. He documents the positive and pertinent negative responses for 10 of the systems and writes: 10 of 14 systems obtained, remainder of systems are negative.
This documentation would count as a complete ROS.
Tips:You can use a form or template to record
ROS.Keep any form as part of the medical
recordWhen referring to old forms, include the
review date and location of the previously recorded information.
Include all 14 systems on form.
PMFSHDon’t need until you get to a detailed history
99214 – or on the new patient side a 99203. In the ED, you’d be talking about a 99284 (… a
detailed history; a detailed examination; and medical decision making of moderate complexity …)
PMFSHA complete PMFSH addresses 2 or 3 of the
PMFSH elements. Established patient visit requires 2 of 3Initial visits and consults requires 3 of 3
A complete PMFSH might support up to 99285. Including: 99204 99205 99215 99219/99220 99222/99223 99254 99255
Patient HistoryPast medical: look for information on the
patient’s allergies, current medications, past illnesses and surgeries, and any conditions that may be relevant to the presenting problem.
Example: A patient is taking insulin to treat her diabetes. The physician notes this, in case he decides to prescribe medication that may interact negatively with insulin.
Patient HistoryFamily history : a review of medical events
in the patient’s family, including diseases that may be hereditary or place the patient at risk. Also includes any inheritable condition or disease that is relevant to why the patient is seeking medical attention.
Example: A patient presents with rectal bleeding. The physician notes that the patient’s family has a history of colon cancer, this will affect treatment
Patient HistorySocial history is just as important as family
and past history.Items you should include:
• workplace• living conditions• marital status• age-appropriate review of past and
current activities
Example: A 50-year-old man presents to the ED with chest
pain.He has been experiencing shortness of breath and
upper extremity discomfort for the past four hours. The patient has a history of coronary artery disease (CAD) and hypertension (HTN). He is and has been a smoker for 20 years, and his father had cardiovascular disease and died of an acute myocardial infarction (MI) at age 53.In this instance, the physician addressed past (CAD,
HTN), family (father’s CAD), and social (smoker) histories. 3 PFSH supports a complete PFSH.
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Codes 99201 99202 99203 99204 99205
History Problem Focused
Expanded Problem Focused
Detailed Comprehensive
Comprehensive
Exam Problem Focused
Expanded Problem Focused
Detailed Comprehensive
Comprehensive
Decision Making
Straight forward
Straight forward
Low complex
Moderate complex
High complex
Time FF 10 20 30 45 60
Key # 3 of 3 3 of 3 3 of 3 3 of 3 3 of 3
Office Visits – Established Patient
Codes 99211 99212 99213 99214 99215
History Not Required
Problem Focused
Expanded Problem Focused
Detailed Comprehensive
Exam Not Required
Problem Focused
Expanded Problem Focused
Detailed Comprehensive
Decision Making
Not Required
Straight Forward
Low Complex
Mod Complex
High complex
Time FF 5 10 15 25 40
Key # 2 of 3 2 of 3 2 of 3 2 of 3 2 of 3
Levels of History
Level of History
Chief Complaint
(CC)
History of Present Illness (HPI)
Review of Systems (ROS)
Past, Family, Social History (PFSH)
CPT Medicare CPT Medicare CPT Medicare
Problem Focused
Required Brief 1-3 elements Not Required Not Required
Expanded Problem Focused
Required Brief 1-3 elements Problem- Pertinent
1 system Not Required
Detailed Required Extended 4 + elements OR 3+ chronic or inactive conditions
Extended 2-9 systems Pertinent 1 element
Comprehensive Required Extended 4 + elements OR 3+ chronic or inactive conditions
Complete 10 systems Complete 2 or 3 elements
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