E/M History Component: A Quick Review

When considering the history component of any evaluation and management (E/M) service, keep in mind the following:

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  • A chief complaint is the reason the patient feels he or she needs care. Unless the encounter is for a preventive medical history and physical, the chief complaint must be easily identifiable. This is the first step towards establishing medical necessity.
  • In the event that a provider is unable to obtain a history from the patient or other source (for example, if the patient is unconscious), he or she is advised to document the reasons surrounding his or her inability to capture this information. Providers will not be penalized, nor will the work they provide automatically discounted, due to these circumstances.
  • Additional history supplied by a family member or a caregiver and documented by the provider can be credited toward the medical decision-making component.
  • Systems review and past family and social history taken from an earlier encounter may be updated, without complete re-documentation, for most payers. The provider must indicate the newly-discovered status of the history, noting that he or she has reviewed pertinent information contributing to the current patient encounter. This provides an audit trail to the original documentation.
  • Although a comprehensive service may be performed and documented, it’s not always medically necessary or billable.
  • The history component is full of subjective terms. Two separate audits of the same service may produce different results. Reviewer A may argue with reviewer B that an element of the history of present illness is a “quality,” versus an “associated sign and symptom or other element.” Reviewer B may assert that documentation of “no known drug allergies” is an element of review of systems or an element of past history. Correct interpretation requires consistency, verifiable references, a logical argument, and—most importantly—medical necessity.

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