8 Tips for Compliant History Component Documentation

By Brandi Tadlock, CPC, CPC-P, CPMA, CPCO

History - arrows and blocksTo 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).

Evaluation and Management – CEMC

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):

  1. 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.
  2. The chief complaint is the patient’s presenting problem. “Follow-up” is not a chief complaint.
  3. 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.
  4. 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.)
  5. 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.
  6. HPI may be documented by the performing provider ONLY. Copying the nurse’s notes does not count.
  7. 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.
  8. 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.

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30 Responses to “8 Tips for Compliant History Component Documentation”

  1. Margaret says:

    Very good info I am always glad to get info on E & M because it is so grey in some areas, I recently reviewd an audit by our compliance person and the encounter too me lacked support for the HPI for the visit to be a level 4 because she indicated that the exam was detailed and and the MDM was mod. we use the 95 DG. I just recently read in an Intellicode book for auditing that since 95 does not define what is an extended exam each facility should defiine what is an extended exam for 95, how can we do this????

    Thanks, I am an auditor in my current position.

  2. Maryann Palmeter says:

    I respectfully disagree with the information provided under bullet #4. This is not correct in regard to 99211 or other levels of established patient or subsequent visits where only 2 of the 3 key components are required to support the level of service billed.

    In regard to bullet #5, this is not correct with respect to established patient or subsequent visits where only 2 of the 3 key components are required to support the level of service billed.

  3. Stefanie says:

    Margaret, I had the same question about the 95 Exam DG and extended definitions: I, fortuantely, found an education series webinar on E/M on our MAC website (Palmetto GBA). They speficially state that an extended exam with “More Detail” consists of at least 2 findings for at least 2 “body areas” or “organ systems”. This was super helpful for me as I also am an auditor in my current position. I suggest you see if your MAC has anything like this. If your MAC is Palmetto GBA, I would be happy to provide you with the link to these webinars.

  4. eusebio m. Montejo MD says:

    The problem with puting into code the cognitive effort and work that is generated in an encounter is that no system can adequately translate such a process. We have ICD system to capture assessment that was never designed for billing purposes. It also, forces a physician to adopt a diagnosis even if incorrect because using the ICD system one cannot capture an assessment that is a working diagnosis, or suspected diagnosis.
    1. The issue of chief complaint;
    This poses a dilemma for most coders and physicians because coders do not understand what this means. An office visit can be and should be initiated by either, patient or physician. A physician initiated visit does not mean that that visit is not medically necessary.
    A brief history of SOAP, is that it was developed to able to communicate between physician and other health providers succinctly and efficiently. Rather than rummaging through an entire chart one can get an accurate picture of a patient by looking at the latest note.
    A patient can come in for a medically necessary office visit for the entire purpose of follow up. For patients and physicians, this is understood and communicable across all healthcare fields. A patient is started on medication for blood pressure not at goal (which there is no ICD-9 diagnosis). A physician should have this patient follow up for management of that blood pressure. Any sane mind would understand this, if in the chief complaint it was written follow up for hypertension.
    CPT excerpt: Chief Complaint: A chief complaint is a concise statement describing the symptom, problem, condition, diagnosis or other factor that is the reason for the encounter. Usually stated in the patient’s words:
    I see no issue with stating patient is here for follow up, and I do not understand why coders insist that this is a problem. The lack of medical education should not be justified by insisting a physician adopt new documentation style to accommodate a coder. It is the coder responsibility to assure documentation compliance… does the note have all the elements to justify the level of coding. Medical necessity is beyond coders.

  5. Laura Donnelly says:

    While I appreciate AAPC for this news, it is not new to the coders, or at least it should not be. Medicare requires the same, and has been holding seminars of same for physician practices. It is imperative that any seminars offered to office staff and physicians involved in the coding and billing of medical claims attend and keep updated on the requirements of billing procedures to avoid audits and/or denials.
    AMA coding books for ICD9 and CPT codes have table guides for physicians when dictating or writing evaluations. There is even an E/M Express Reference Tables Pocket Guide, perfect for those who wish to glance and be assured they are adhering the the documentation guidelines.
    No office, coder,biller, or auditor should be billing without using these books. Open the books, and read for efficient coding and billing.

  6. Nichole says:

    I have Issues with #4 of this article: “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”.

    At the bottom of page 8 of the CMS E&M guide It is specifically stated “While documentation of the CC is required for all levels, the extent of information gathered for the remaining elements related to a patient’s history is dependent upon clinical judgment and the nature of the presenting problem.”

    This indicates the cc is REQUIRED, but the HPI is not.

    http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/eval_mgmt_serv_guide-ICN006764.pdf

  7. Brandi Tadlock says:

    Maryann, you bring up an interesting point. There is some debate over the interpretation of the guidelines, in reference to established patient visits – while 2/3 key components are used to determine the overall level of E/M service, I interpret the guideline as still requiring all 3 components to be documented (unless the visit consists primarily of counseling/coordination of care, in which case, components like the exam may not be necessary). But, there are other well-respected coders who disagree with that interpretation – it’s a controversial topic, to say the least. Stefanie is correct to refer you to a MAC, but I would suggest referring to your specific MAC’s guidance for interpretation, as the guidelines tend to vary significantly, between different jurisdictions.
    As for 99211, you are correct, in stating that no key components, including the History component, are required in order to report it. However, there must be a presenting problem of some sort, in order to qualify the visit as “problem-oriented”. To bill for the service, it must be documented, and the documentation must support medical necessity; therefore, it would be necessary to document the chief complaint, even though the provider is not striving to satisfy the History Component requirements.
    HPI absolutely must be documented by the rendering provider, and may not be documented by ancillary staff, per CMS Documentation Guidelines.

  8. Brandi Tadlock says:

    Nichole,
    All levels of the History Component, from Problem-Focused to Comprehensive, require, at minimum, a brief HPI, meaning that at least 1 element of HPI, or the status of 1 chronic condition, must be documented. Please refer to CPT Guidelines, under “Determine the Extent of History Obtained”, on page 9 of the AMA CPT 2013 Manual.

  9. Brandi Tadlock says:

    Dr. Montejo –
    What you call ‘problematic’, coders call ‘job security’. ;)

  10. Nichole says:

    Brandi, I understand that in order to qualify for any level of history you need an hpi; however, #4 is saying that every ENCOUNTER has to have a history. This is where I get confused. Isn’t it acceptable to have a CC, Exam, and MDM to meet your level of E&M? If not, could you direct me to the documentation that says otherwise? Thanks

  11. Nichole says:

    Oh, to amend my question, I do mean for those E&M’s that only require 2/3 components to qualify such as the 99211-99215 series of codes

  12. Brandi Tadlock says:

    Nichole,
    Please refer to my comment to Maryann, for my answer to that – in my opinion, the answer is yes, but I’m not the authority on the subject. I would advise you to check with your MAC for specific guidance, as neither CPT nor CMS guidelines definitively explain that subject.

  13. Brandi Dredge says:

    Hi Brandi,
    I would like to clarify line #2 because I feel that was maybe misunderstood by Dr. Montejo. The way I (as a coder) read line #2 is that “follow up” isn’t an acceptable CC however “follow up blood pressure” would be an acceptable CC? We edcuate to our providers that the CC should clearly state the intent of the visit and simply using the wording “follow up” doesn’t show a clear reason for the visit.

  14. Cynthia says:

    I agree with Dr. Montejo’s comment…Medical necessity is beyond coders. Our job as coders is to follow the guidelines and bill to the level documented. Sometimes it is very hard to choose between level 4 and level 5’s due to medical necessity. All documentation is there for a level 5 but does it meet medical necessity? I believe as coders we don’t have the medical training to be making that decision. Yes, it is the doctors responsibility to “tell us the story”, but should we be making the call to downcode due to medical necessity?

  15. Chris says:

    Margaret: Most Part B Medicare carriers will identify what they determine to be a detailed exam. For example Novitas (for J12 and JH) states 4×4 must be documented to be a detailed exam under 95 guidelines. 4 ORGAN SYSTEMS with ELEMENTS documented in each.

  16. Chris says:

    Margaret: Sorry that was to read FOUR (4) ELEMENTS documented in each of 4 organ systems.

  17. Brandi Tadlock says:

    Medical necessity is not easily quantified, but determining the overall nature of the presenting problem, is crucial to accurate code selection. That’s why the guidelines include the table of risk, and why CPT has clinical examples, in Appendix C – to serve as a way to gauge the severity of the patient’s problem, by comparing it to similar problems. Ultimately, medical necessity should be determined using the provider’s discretion. If you’re unsure, always ask the provider for clarification, or their opinion.
    I call level 4’s and 5’s “one foot in the grave” codes, because they indicate a very severe problem, that needs immediate attention, or the problem or its treatment, may have more severe risk factors, than your average prescription. Here are a couple of vague examples (definitely NOT all inclusive):
    Level 2 – illnesses or injuries that would probably clear up on their own, without medical attention
    Level 3 – illness that requires a prescription to clear up, but nothing so severe that it’s going to cause serious harm to the patient, if they don’t see the doctor immediately; routine maintainance of an established problem that requires a prescription
    Level 4 – Illness that has a reasonable probability of putting the patient in the hospital, or progressing to loss of organ function, if left untreated; development of new symptoms or symptomatic episodes, in an established problem (including no/poor response to treatment)
    Level 5 – Illness has a high probability of resulting in hospitalization, loss of organ function, or death if left untreated; patient has risk factors, like multiple chronic illnesses, compromised immune system, extreme age, that complicate the symptoms of a new problem; patient experiences sudden, drastic change in status, of a previously well-controlled illness.

    Hope that helps!

  18. Brandi Tadlock says:

    Yes, Brandi – “follow up on blood pressure” would be acceptable as a CC, but that alone, would not be sufficient to qualify as the status of a chronic illness, for HPI (Not that you asked…I just wanted to point that out, because I’ve seen it, before…).

  19. Mary says:

    We know medical necessity is the overriding criteria over elements. How do we get there? How can we help our providers and ourselves at the same time in terms of levels of service and meet documentation requirements? Here’s what I’ve done with one department and am currently working with another department. It also helps with building a repoire with providers. Example: run a report on the top 50 diagnoses used in the clinic. Review a certain number of chart notes on each provider. Bring those notes with you and sit with a provider who has extensive knowledge about those diagnoses and risk factors associated with those diagnoses. Have the provider help you categorize those diagnoses under risk factors 1,2, 3 or 4. The higher the risk factor (MDM), the more documentation that is needed under the HPI/ROS/PFSH/Exam. You learn more about your specialty, the provider knows what he/she should be documenting and understands WHY he/she is documenting/needing to select the components to meet the level of service.

  20. trina says:

    I believe in the article when stating each encounter needs a CC, and “follow up” is not enough what the author was trying to say is just that. It can’t just say “follow up” it must state “follow up on xxxx”

    Say for instance the patient has more than one problem, and all the chart says is follow up or med refill…follow up on what? med refill for what? I have seen many charts that this is it, and then the provider puts in the assessment the refills of the meds, and the dx.

    The more that is in the chart the better.

  21. Jenny Easter says:

    According to CMS guidelines for an established patient office visit (99211 – 99215) two of the three elements of the visit (history, exam, MDM) must meet the documentation requirements in order to bill a specific level. The medical decision making should be the driving factor behind the code in the sense that a minimal or low risk problem on its own would not necessarily justify the provider performing a detailed or comprehensive exam. A child who fell down on the playground and has a small cut on the leg would not necessarily need to have a detailed exam performed on them in order to receive appropriate medical treatment. Other factors, such as past medical history or family history could add to this risk in other situations, however the provider should be clear as to what these factors are.

    I disagree with Brandi’s description of level 4 and 5 codes as “foot in the grave” codes, because according to CMS’ table of risk, prescription drug management is considered moderate risk. Based on this, a new problem requiring a prescription should easily meet the requirements for billing 99214 as long as the provider has included a decent history. As for a new patient to a practice, 99204 requires a comprehensive history and exam but only moderate risk. If this is the first time that a patient is seen in a practice I could justify billing a higher code like this in order to get a good baseline history and exam of the patient.

    As for Dr. Montejo’s comment
    “I see no issue with stating patient is here for follow up, and I do not understand why coders insist that this is a problem. The lack of medical education should not be justified by insisting a physician adopt new documentation style to accommodate a coder. It is the coder responsibility to assure documentation compliance… does the note have all the elements to justify the level of coding. Medical necessity is beyond coders,”
    as coders it is our responsibility to accurately code procedures or levels of care based on the documentation that is provided. We are not to make assumptions – if it is not documented it did not happen. It is the provider’s responsibility to make sure that the documentation clearly and accurately represents the nature of the visit and what happened therein. It has nothing to do with lack of medical education, it is a matter of quality and continuity of care. This documentation is not there to remind the provider of a particular visit with a patient or to jot their memory – it is there so that everyone else involved with that patient’s care also knows what is going on with them, what signs or symptoms they may have had in the past, treatments or medications that they have received. The issue isn’t that the patient is there for a follow up visit, it is the fact that the provider fails to include the reason for follow up – “follow up of hypertension” is a valid chief complaint as compared to simply “follow up” is not.

  22. Pam Miller says:

    @Jenny Easter–very well said. @Dr. Montejo, when you say that you don’t understand why coders insist that this is a problem, I hope you understand that the coder you hired did not make up the rules. They did not decide it was a problem–CMS did. Believe me that your coder doesn’t want to have to tell you time and time again that you need to state things a certain way. You hired your coder to make sure that you are getting paid for you did, but the flip side of that is that they cannot bill for what isn’t documented. If you take your car to the mechanic for a loud noise in the front end, are you just going to pay the amount that they tell you to or are you going to ask them exactly what they did? A mechanic doesn’t like paperwork any more than a physician does, but it is what is necessary for proper payment. But more importantly, as Jenny stated, it is there so that everyone else involved with that patient’s care knows what is going with them and what has been done in the past so that today’s treatment will be the most appropriate.

  23. Victor says:

    Follow-up still indicates what the patient is coming in for, which is all you need for the Chief complaint. The note the day of service and prior note should indicate what that follow up was for. Each note is not in its own bubble, and some investigation by the coder maybe necessary. Work should not be translated back to the physician just to make the coders life simpler. My experiences with Electronic Medical Records is that they further muddy the water because they often pull CC directly from the schedule. So maybe the physician has documented what they want the patient back in for on their note, and maybe they do a work-up for that reason, it still doesn’t always translate depending on the EMR or even other human errors.

    I have seen a lot of indication on what everyone would like to have, and I agree “follow-up hypertension” feels better, but is it what the record MUST have? Directly from 1997 documentation guidlines “The CC is a concise statement describing…physician reommended return” and that to me is met with just follow-up.

  24. Charumathi says:

    It is a useful document but very basic one where only learners can be benefited add few more points which really help in audit compliance. And i also really regret with point 6 As some of the document contains HPI as reviewed from Nurses notes for a straight forward and a moderate HPi.

  25. Debi, CPC, CEMC says:

    @ Victor – When auditing a note, as a coder, I do not have access to the rest of the chart. I only have access to the one dictation in front of me. So, if a note states CC: Follow up – it is not a billable visit in our setting. I do E/M coding for a Hospice and spend many hours working with physicians to help educate them in the proper way to dictate, if you want to be paid. It is an age old argument, but everyone needs to remember, we are on the side of the physician. We want them to be paid and if audited by CMS, to not have to pay any penalties!! That is why we have jobs. We are here to help, not hinder.

  26. Brooke says:

    In statement #8: Indicates that the provider must reference the information in his or her own notes. Does the provider need to date and initial the information on the sheet that they are referencing, in addition? Thanks.

  27. Michael Elliott says:

    I know I’m coming a year late to this topic, but I’ve got a question.

    I always use the MDM as my guideline for coding (I am a physician), as either the history or exam are usually sufficient to meet meet a given level of code. But it’s the 99215/99205 that I have a hard time figuring out. FYI, I’m in Novitas territory.

    MDM is made up of Risk, Data and Diagnoses. The coding guidelines specifically state that only 2 of the 3 are needed to justify MDM. Yet there is the “nature of the presenting problem” as the overriding imperative.

    My question is: can you get a particular level of MDM (specifically High Complexity) by using Data + Diagnoses?

    Example: 50 year old man with prior CAD is scheduled for follow up of his hyperlipidemia and hypertension, but also presents with a new complaint of a month-long history of dyspnea. An EKG and chest X-ray are done in clinic. Previously ordered lab (CMP, lipids) are reviewed, but a CBC is also ordered due to the dyspnea. A stress test is ordered. The diagnoses addressed are: 1) dyspnea (new problem/further workup planned) 2) hyperlipidemia (established/stable) 3) hypertension (established/stable).

    MDM: Data=5 points (lab=1, X-ray plus interp=2, EKG=1, stress test=1). Diagnoses=6 points (new problem with workup planned=4 points, plus two 1-point established/stable problems). Risk=moderate (undiagnosed new problem). Based on needing 2 out of 3 of them, the MDM would be High (data+diagnoses/treatment options)

    As far as history or exam, doing a comprehensive history or exam is actually pretty easy in the situation of a cardiovascular or pulmonary problem, so let’s just for the sake of argument say that one or the other is sufficient.

    MDM=High plus either exam or history=comprehensive would come out to a 99215

    So I guess the big question is: is it possible to get a High level of complexity of MDM “just” using Data + Diagnoses? If the “nature of the presenting complaint” is so important, then why even list the “two out of three” rule for determining MDM?

    Thoughts?

  28. Kim Dziekan says:

    Can anyone please direct me to a link/resource/site that is reputable (i.e. well-known coding organization, governmental agency like CMS, etc. (not MAC’s)) that clearly state the the physician/provider MUST be the one to document/reiterate/validate the chief complaint and/or even though ancilary staff have documented it, he still has to as well in order to get credit for the history component? the CMS E/M Service guide does not include the chief complaint as a component that CAN be documented by ancillary staff, however, it doesn’t clearly state it HAS to be documented by the physician. We need a reference to support that it HAS to be documented by the physician.

  29. Christy Mansuy says:

    Dr. Elliott, you are correct. if your data and # of dx = comprehensive and your risk is a moderate the 2 out of 3 rule makes your MDM High therefore if your Hx and/or Exam is comprehensive (depending on the patient’s status NEW or EST) you meet the criteria for 99205 or 99215. the nature of the presenting problem maybe moderate but the diagnostic procedures and management/treatment options represents also the complexity of your decision making.

  30. Cheryl Bouschor, CMA(AAMA), CPC says:

    @Victor, in agreement with Debi, CMS requires that EACH progress note be able to ‘stand alone’ in supporting the medical necessity of the visit. If CMS (or any insurance) requests a copy of the documentation, it will be that one note. Without the chart, the chief complaint of follow up does NOT tell what medically indicated problem the patient is here for today. In the instance of a family practitioner who may be following MANY different conditions in the patient, how would one know whether we are seeing the patient for a recheck of a sinus problem, rather than one of his/her chronic condition without the chief complaint? Futhermore, this may be extremely important documentation in a a case where a patient has a workman’s compensation, liability, or auto injury they are being followed for, along with chronic conditions, such as diabetes or hypertension. That chief complaint can set those carriers straight on exactly why that patient was here for that visit. It must be clear that they are or are not here for follow-up to their liability condition in order to be processed by a liability carrier.

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