Published in the December 2007 issue of Today’s Hospitalist
Many physicians may not realize how important it is to document all the components of a patient’s history. But failing to do so can seriously erode the bottom line.
Unlike performing a physical exam, where physicians need to count only one area, you must consider several elements of a history before choosing the right code. According to guidelines from the Centers for Medicare and Medicaid Services (CMS), there are four elements to take into account before picking a code for an initial hospital visit (99221-99223), an inpatient subsequent visit (99231-99233) or an inpatient consultation (99251-99255). Those elements are:
“¢ chief complaint;
“¢ history of present illness;
“¢ past, family and social history; and
“¢ review of systems.
Documenting the chief complaint is never a problem. But the other elements have exacting documentation standards that must be followed to maximize reimbursement.
History of present illness
Physicians can cover up to eight separate categories in the history of present illness. To meet the highest level for any code set, doctors have to document four or more of those categories.
Here are the eight categories that can be considered, with an example of each:
“¢Location: Pain in left chest
“¢Quality: Throbbing pain in left chest
“¢Severity: Throbbing pain in left chest with pain scale of 9/10
“¢Duration: Throbbing pain in left chest with pain scale of 9/10, lasts for 2-minute intervals
“¢Timing: Throbbing pain in left chest with pain scale of 9/10 since this morning
“¢Context: Patient was walking to the car when experienced left chest pain
“¢Modifying factors: Patient takes one baby aspirin a day
“¢Associated signs and symptoms: Patient has some shortness of breath with left chest pain
Past medical, family and social history
After calculating the history of present illness, physicians need to look at “and document “past medical, family and social history. Keep in mind that all past medical conditions, surgeries, allergies and medications qualify for this section. Also remember that omitting any portion, such as social or family history factors, will be bad news for your reimbursement.
According to CMS guidelines, you need to make only one comment for each category. Here are some examples:
“¢ Past medical: No known allergies
“¢ Family: Mother died of breast cancer
“¢ Social: Doesn’t smoke
Physicians have gotten in the habit of referring to one of these elements as “non-contributory.” But auditors increasingly frown on that practice.
Saying, for instance, that family history is “non-contributory” doesn’t tell an auditor whether you’ve actually reviewed the history. A better option would be to say, “Family history reviewed and is non-contributory to patient’s illness.” That removes any doubt that you reviewed the element and took it into account.
When documenting social history, the following items are acceptable: current employment; occupational history; marital status/living arrangement; use of drugs/alcohol/ tobacco; level of education; and sexual history. Some physicians stumble over what to include for pediatric cases. For these patients, you can put in the history of immunizations as well as living arrangements with parents or school history.
Review of systems
In this part of the history, you interview patients to find out how management
options might affect their signs and symptoms.
The CMS outlines the following 14 systems: constitutional; eyes; ears/nose/throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; neurological; psychiatric; endocrine; integumentary; hematologic/lymphatic; and allergic/immunologic.
As a documentation shortcut, the CMS allows you to note all the pertinent positive systems (two or more), then state that “all other systems reviewed and are negative.” You need to include only one comment for each system reviewed.
Putting it all together
The chart above shows all these components come together to determine a level of history.
You will run into some situations where is counting tool does not apply. If a patient presents to the hospital while intubated, for instance, you will not be able to gather information for many elements.
In such cases, document why you weren’t able to obtain the patient history. Acceptable reasons include intubation, altered level of consciousness, poor historian and language barriers.
If, however, family members or caretakers can provide the history, be sure to obtain and include it in both your decision-making and documentation.
When in doubt on what to document, err on the side of too much, not too little. Forgetting to include just one or two details about patient history can reduce a level three initial admit to a level one. And that can have serious financial repercussions for your practice.
Tamra McLain is an independent coding consultant in Southern California. E-mail her your documentation and coding questions to firstname.lastname@example.org, or send a fax to 888-202-1601. We’ll answer your questions in a future issue of Today’s Hospitalist.