8 Tips for Compliant History Component Documentation
By Brandi Tadlock, CPC, CPC-P, CPMA, CPCO
To ensure high quality patient care and proper reimbursement, and to help protect you from audits, evaluation and management (E/M) documentation must meet or exceed complex requirements for every encounter. When it comes to determining medical necessity—the overarching criterion for payment—for E/M services, one area of provider documentation that is typically deficient is the history of present illness (HPI).
Documentation of the history element of an E/M service tells a story about an illness, and how it has affected a patient. The story must have a beginning, some development, and an ending to adequately describe the E/M of the patient’s presenting problem(s). To help you meet documentation requirements, specifically relating to the history component, let’s take a closer look at the requirements, as laid out by the Centers for Medicare & Medicaid Services (CMS):
- Every encounter must have a chief complaint. It can be separate from the HPI and review of systems (ROS), or it can be part of the HPI or ROS; but it must make the reason for the visit obvious.
- The chief complaint is the patient’s presenting problem. “Follow-up” is not a chief complaint.
- If the patient doesn’t have a problem (for instance, she just needs an annual exam), there is no chief complaint. You must bill a preventive E/M service.
- Every encounter must have a minimum of one HPI or the status of at least one chronic illness. The provider must describe the problem (how bad it is, how long it has been going on, etc.)
- Visits that will be billed at a high level E/M (level IV or V, for most categories) must have at least four HPI documented, or the status of three or more chronic illnesses. The problem has to be serious enough to justify a higher level of service, and the medical record must reflect this.
- HPI may be documented by the performing provider ONLY. Copying the nurse’s notes does not count.
- ROS is the patient’s positive and negative responses about his or her experiences with symptoms. ROS is the patient’s observations, not those of the provider.
- ROS and past, family, social history (PFSH) may be recorded by someone other than the provider (e.g., ancillary staff, the patient), as long as the provider references the information in his or her own notes.
There are a lot of nuances to understanding the different elements of HPI. Some, such as location and severity, are pretty straightforward. Others, such as timing and context, can be more difficult to spot. To help you understand this better, be sure to read the May 2013 issue of Cutting Edge, where we will cover this topic in depth.