5 Key Points About the E/M History Component
When evaluating documentation for the history component of an evaluation and management (E/M) service, keep in mind:
- A chief complaint is a medically necessary reason for the patient to be meeting with the physician. A readily identifiable chief complaint is the first step in establishing medical necessity. Without a chief complaint, the service is preventive.
- If documentation substantiates that the provider is unable to obtain a history from the patient or other source (e.g., the patient is unconscious), the provider is not penalized, nor are the overall level of medical necessity and/or provider work discounted automatically.
- When additional history is supplied by a family member or a caregiver and documented by the provider, this can be credited toward the medical decision-making (MDM) component of the service.
- A review of systems (ROS) and past family and social history (PFSH) taken from an earlier encounter may be cited without re-documentation for most payers. The provider should indicate the new status of the history and note where the original documentation may be found.
- The history component includes many subjective terms. For example, auditor A may argue that an element of the history of present illness (HPI) is a “quality,” while auditor B may feel it is an “associated sign and symptom or other element.” Auditors may differ as to whether “no known drug allergies” constitutes an element of ROS, or an element of PFSH. Because accurate coding relies on counting subjective elements, the correct interpretation requires consistency, verifiable references, a logical argument, and ultimately, medical necessity.