The Driving Parts of E/M Level Selection: Part 1

Part 1 of this three-part series provides an in-depth look at the history component.

By Raemarie Jimenez, CPC, CPC-I, CANPC, CRHC

Although evaluation and management (E/M) comprises a significant portion of coded services in most physician practices and medical facilities, selecting an appropriate E/M service level can flummox even an experienced coder. Over the next several months, Coding Edge will discuss, in turn, each of the three key components that drive level selection for the majority of E/M services: history, examination, and medical decision-making (MDM). This series will provide the basic information you need to not only choose E/M service levels with confidence, but also audit E/M claims for accuracy and consistency. We begin with the history component.

Evaluation and Management – CEMC

CPT® defines four levels of history, as determined by the amount and depth of information the practitioner collects from the patient. These include:

  • Problem focused
  • Expanded problem-focused
  • Detailed
  • Comprehensive

The history component of any E/M service is further divided into constituent elements, as defined by 1995 and 1997 DocumentationGuidelines for Evaluation and Management Services. The specific elements that determine the history level include:

  • History of present illness (HPI)
  • Review of systems (ROS)
  • Past family and social history (PFSH)

You can access both 1995 and 1997 E/M documentation guidelines on the Centers for Medicare & Medicaid Services (CMS) website at www.cms.hhs.gov/MLNEdwebGuide/25_EMDOC.asp.

Slot HPI Into One of Two Levels

The HPI is a chronological description the patient’s present illness development, from the first sign or symptom, or previous encounter, to the present. Under both the 1995 and 1997 E/M documentation guidelines, the HPI can be quantified by a patient’s statements regarding:

  • Location: The anatomical place, position, or site of the chief complaint (eg, back pain, sore elbow, cut on leg, etc.)
  • Quality: A problem’s characteristics, such as how it looks or feels (eg, yellow discharge, popping knee, throbbing pain, etc.)
  • Severity: A degree or measurement of how bad it is (eg, improved, unbearable pain, blood sugar 205, etc.)
  • Duration: How long the complaint has been occurring, or when it first occurred (eg, since childhood, first noticed a month ago, on and off for several weeks, etc.)
    Timing: A measurement of when, or at what frequency, he or she notices a problem (eg, intermittent, constant, only in the evening, etc.)
  • Context: What the patient was doing, environmental factors, and/or circumstances surrounding the complaint (eg, while standing, during exercise, after a fall, etc.)
  • Modifying factors: Anything that makes the problem better or worse (eg, improves with aspirin, worse when sitting, better when lying down, etc.)
  • Associated signs and symptoms: Additional complaints that may be related.

The 1997 E/M documentation guidelines also allow credit in the HPI for patients who are seen for chronic conditions, such as if the patient states, “I am here today to follow up with my COPD.” Statements of this type are not credited specifically under the 1995 E/M documentation guidelines, but may be given credit by the 1997 E/M documentation guidelines as chronic conditions when the status of those conditions are the reason for the visit.

Important: Do not “mix and match” 1995 and 1997 documentation guidelines. If you select 1997 E/M documentation guidelines for the history component, you should use the same guidelines to determine the exam level and medical decision making level.

There are only two HPI levels. The least amount of credit defined by the HPI (assuming that HPI is documented) is a brief HPI, which correlates to an expanded problem-focused work level. For both 1995 and 1997 E/M documentation guidelines, the HPI is brief if at least one of the eight elements that quantify HPI (location, quality, severity, etc.) is documented.

The second HPI level, an extended HPI, correlates to a comprehensive work level. For both 1995 and 1997 documentation guidelines, the HPI is extended if at least four of the eight elements that quantify HPI are documented. For 1997 E/M documentation guidelines only, patient statements regarding the status of at least three chronic conditions may also be considered an extended HPI.

Refer to the History Level Selection Chart to determine how HPI correlates to the four levels of the overall history component:

For example, a comprehensive history is required for a level IV new patient visit (99204 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A comprehensive history; a comprehensive examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 45 minutes face-to-face with the patient and/or family). To meet the work of a comprehensive history, an extended HPI (four of eight HPI quantifiers or the status of at least three chronic conditions when using 1997 documentation guidelines) must be documented.

Calculate ROS by Reviewed Body Systems

Both 1995 and 1997 E/M documentation guidelines define the ROS as an account of body systems obtained through questioning to identify patient signs and/or symptoms. The ROS might include verbal questioning by the provider or by a separate patient intake or questionnaire form. The ROS may include the systems directly related to the problems identified in the HPI and/or additional body systems.

The ROS recognized 14 body systems are:

1.     Constitutional

2.     Respiratory

3.     Integumentary

4.     Psychiatric

5.     Eyes

6.     Gastrointestinal

7.     Neurological

8.     Allergic

9.     Ears, Nose and Throat

10.     Genitourinary

11.     Endocrine

12.     Cardiovascular

13.     Musculoskeletal

14.     Hematologic and Lymphatic

There are only three ROS levels. The least amount of credit defined by the ROS—assuming that at least one system is reviewed and documented—is a problem-pertinent ROS. The second ROS level, an extended ROS, requires a documented review of at least two of the 14 organ systems. The final ROS level, a complete ROS, requires a documented review of at least 10 of the 14 organ systems.

Refer to the History Level Selection Chart to determine how ROS correlates to the overall history component’s four levels.

For example, a level IV new patient visit (99204) requires a comprehensive history. To meet the work of a comprehensive history, a complete ROS (review of at least 10 of 14 organ systems) must be documented.

Medical necessity determines the extent of the ROS. For instance, it might be considered necessary to obtain a complete ROS when a new patient presents, but medically unnecessary to repeat that complete review on every follow-up.

For most payers, if there is separate documentation of at least one pertinent positive or negative ROS element, and the provider states the remaining systems are reviewed and negative, credit should be given for a complete ROS. For example, the ROS in a new patient visiting a cardiologist may read, “Denies additional cardiac complaints; the remaining systems were reviewed and otherwise negative.”

PFSH is Either Pertinent or Complete

The patient’s past history includes previous diseases, illnesses, operations, injuries, treatments, and medications. If a patient presents for follow-up on a chronic condition, both the HPI and past history should be considered. Positive findings of past diagnoses discovered on ROS should also be considered.

Family history is a review of medical events in the patient’s family, including the parents and other relatives’ age of death, and diseases that may be hereditary or place the patient at an increased risk.

Social history is a review of the patient’s past and current activities, such as the patient’s occupation, whether he or she smokes or drinks alcohol, engages in sexual activity, and is married. Social history should be age appropriate. For example, it would not be reasonable to document that a 6-year-old is not married.

Inquiries about the patient’s PFSH may be made by the provider, obtained by the staff, or gathered via a form completed by the patient.

There are only two PFSH levels. The least amount of credit defined by the PFSH—assuming that PFSH is documented—is a pertinent PFSH, which correlates to (at least) a detailed work level. For both 1995 and 1997 documentation guidelines, the PFSH is pertinent if at least one of the three constituent categories (past history, family history or social history) is documented.

The second level of PFSH, a complete PFSH, correlates to a comprehensive work level. This requires a documented review of two of three constituent categories (past history, family history, and social history) for established patient office or other outpatient services, emergency department, established patient domiciliary care, and established patient home care; or documented review of all three constituent categories (past history, family history, and social history) for new patient office or other outpatient services, hospital observation services, hospital inpatient services, consultations, comprehensive nursing facility assessments, new patient domiciliary care, and new patient home care.

Refer to the History Level Selection Chart to determine how PFSH correlates to the overall history component’s four levels:

For example, a level IV new patient visit (99204) requires a comprehensive history. To meet the comprehensive history work, a complete PFSH must be documented.

Put It All Together

All three history elements must support the work level to meet the overall history level requirement. The lowest element within the history component will always determine the overall history level.

For example, if the HPI and ROS both support a detailed history level, but the PFSH supports only an expanded problem-focused history level, the history level will stay at the expanded problem-focused level.

Raemarie Jimenez, CPC, CPC-I, CANPC, CRHC is the AAPC’s director of exam content.

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