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Are you covering all bases when choosing a level of history?
by Tamra McLain, CPC, CPC-H, CMC



Published in the June 2006 issue of Today's Hospitalist

You know that the history of present illness is a major part of choosing a level of history for your patients, but do you know that it is only one of several elements that you must use to justify evaluation and management codes?

More than occasionally, physicians tell me that they’re unaware of all the elements that go into choosing a level of history when selecting evaluation and management codes. The truth is that guidelines from the Centers for Medicare and Medicaid Services (CMS) very clearly state that patient history must include the following four elements:

1) chief complaint;
2) history of present illness;
3) past, family and social history; and
4) review of systems.

These elements may seem egregious and even repetitious, but by ignoring them, you put yourself at risk of trouble from auditors if you ignore them. That’s particularly true when you choose moderate and high levels of service.

Here’s an overview of the elements that should go into choosing a level of patient history, and help you steer clear of trouble.

History of present illness

The first element, chief complaint, is self-explanatory, so we’ll start with the second item, the history of present illness (HPI). If this sounds just as obvious as listing the chief complaint, think again. You should use this element to describe the onset of a patient’s signs or symptoms by using one or more of the following points. For this example, we’ll refer to a patient who presents with abdominal pain:

• Location: Pain in the RU abdomen.

• Quality: Diffused pain RU abdomen.

• Severity: Diffused pain x 4 in severity in RU abdomen.

• Duration: Diffused pain x 4 in severity in RU abdomen x 1 day.

• Timing: Diffused pain x 4 in severity in RU abdomen x 1 day, worse after meals and at night.

• Context: Diffused pain x 4 in severity in RU abdomen x 1 day, worse after meals and at night; patient states the pain started after eating seafood for dinner.

When it comes to assigning a value to the history of present illness, you can choose from two levels: brief or extended. If you describe the history of present illness as brief, you’ll need one to three of the above elements. To accurately describe the history of present illness as extended, you’ll need four or more of the above elements.

Past, family and social history:

If you’re treating a patient whose condition is more complex, you can designate it using the past, family and social history. To simplify matters, we’ll describe this section one element at a time. First, the term “past” typically refers to items like prior illnesses or injuries, past surgeries, allergies, medications or immunizations. Next, “family history” describes diseases or conditions that may affect the current treatment of the patient.

(It is worth noting that simply stating that family history elements are “noncontributory” to your patient’s history can lead to problems with auditors. You should instead note that the family history was reviewed and is “non-contributory to patient’s current condition.”)

“Social history” generally refers to one of the following elements: current employment, occupational history, marital status/living arrangements, use of drugs/alcohol/tobacco, level of education or sexual history.

You don’t need to write a book to describe each of the above elements. According to CMS guidelines, each category of the past, family and social history can be summed up with one simple statement for each element.

There are two levels of the past, family and social history that you can choose. To choose the category of problem-pertinent (the lowest level), you need to meet one category. To choose the category of comprehensive past, you must meet two to three out of the three, based on the evaluation and management service provided.

Finally, it’s important to note that during subsequent hospital visits, you can perform what’s known as an interval history. That means that you don’t have to collect all of the details of the past, family, and social history, which has not changed during every encounter.

Review of systems

The final component of the patient history is the review of systems. Think of this as a verbal interview with patients to get their perspective on their signs and symptoms that are affected by management options.

CMS guidelines say that the following 14 systems should be considered in a review of systems: constitutional; eyes, ears/nose/ throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; neurological; psychiatric; endocrine; integumentary; hematologic/lymphatic; and allergic/immunologic.

There are three levels to choose from for a review of systems. Problem-pertinent, the lowest level, requires you to review only one system, while the category known as extended requires you to review two to nine systems. The highest level, complete, requires you to review 10-plus systems.

The CMS allows for brevity when it comes to a review of these systems. To properly review an individual system, you need to write down only one comment for every review that is positive. When it comes to describing systems that are negative, CMS guidelines say that you can simply use the following language: “All other systems reviewed and are negative.”

Choosing an overall level of service

The four levels of history—problem-focused, expanded problem-focused, detailed and comprehensive—require a progressive amount of effort from you, so make sure that you can document all of the work you put into your patient histories.



Finally, the box above reviews the level of history from a slightly different perspective: how some evaluation and management codes commonly used by hospitalists typically translate into levels of history.

As you can see, the requirements for the initial inpatient visits are quite stringent. This is the quickest way that your evaluation and management codes can be dropped from a level three to a level one, so remembering to be diligent in documenting patient histories will alleviate unnecessary down-coding and help optimize reimbursement.

Tamra McLain is an independent coding consultant in southern California. E-mail your documentation and coding questions to her, or send a fax to 888-202-1601. We’ll answer your questions in a future issue of Today’s Hospitalist.

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