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:

Evaluation and Management – CEMC

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
John Verhovshek
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John Verhovshek, MA, CPC, is a contributing editor at AAPC. He has been covering medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University.

No Responses to “5 Key Points About the E/M History Component”

  1. Joan Gilhooly says:

    1 (a) Don’t forget that the chief complaint can be described by the provider’s documentation of the history of present illness (HPI). It does not need to be a separate statement. The “DG” in the Medicare Documentation Guidelines simply states that “the medical record must clearly reflect the chief complaint”.
    1 (b) Don’t forget that a patient can still be asymptomatic but still have a medical complaint. A patient who is “feeling fine” or who has “no complaints” is not receiving a preventive service if the reason the physician wanted the patient to make this appointment was so that the status of their chronic medical problems could be evaluated.
    1 (c) It would probably be more accurate to say that there will be “no history of present illness” when the patient is receiving a preventive service — for the simple reason that if the reason for the visit is to provide a screening/preventive service, there is no medical problem to evaluate. Yes, that’s the same as “no chief complaint”. I just didn’t want readers to misunderstand what the author was saying and “assume” that if there was no chief complaint STATEMENT, that the evaluation was automatically a preventive service.
    (2) Don’t forget, though, that the provider is responsible for documenting that he/she has attempted to obtain information from other sources, though. You can’t automatically credit the “unable to obtain history” because the PATIENT is unable to give it if the provider hasn’t documented what the HAVE been able to obtain from family members, other caregivers, the patient’s historical medical record, EMS staff, nursing home staff, etc.
    (3) While the Marshfield “points” system does allow one additional “point” for Amt/Complexity of data towards the overall complexity of MDM when history information is obtained by family members, realistically, this rarely IF EVER results in a higher level of service for the encounter. Go ahead and “count” it. But REALLY be cautious about reporting the higher level of service if this is the SOLE FACTOR on which the higher level of service hinges. Chances are if/when that happens, the lower level of service (the one you would have had without that extra “point”) is generally the right level of service for the TRUE clinical complexity of the encounter.
    (4) In the office setting, a complete ROS and PFSH obtained from an earlier encounter is ONLY required, coding-wise, when the encounter otherwise should be reported with 99215. 99214 only requires a minimum of 2 ROS and 1 PFSH (which you’ll get if the office checks the patient’s meds at each office visit. As coders and auditors, we should discourage the physician from automatically referring to previously obtained ROS and have them focus on documenting only that ROS that was medically necessary for them to obtain for today’s encounter.
    (5) (a) “No known allergies” is NEVER ROS for the “Allergic System”. Look at the CPT manual. It tells you that ROS is an inventory of *signs* and/or “symptoms”, which the statement “no known drug allergies” certainly is NOT!! “No know drug allergies” is ALWAYS part of the patient’s past medical history (ie, it’s a PFSH element).
    5 (b) Re: HPI elements, I’ve got a problem with this, too. 99.9% of the time when I see auditors classifying the same phrase as different HPI elements, what I’m seeing is people who don’t understand the clinical context of what they’re reading. A “quality” statement is always going to be stated as an adjective like “burning”, “stabbing” “dark”, “green”, clear”. There is absolutely no way that one auditor would call a piece of HPI information as “quality” when another would call it “associated signs/symptoms” unless one (or both??) of them didn’t know the clinical significance of the information they were looking at. I’ve been teaching E/M since the codes came out in 1992 and auditing (and teaching auditors) for more than 15 years. And I can say with absolute certainty that there’s only a couple of HPI elements where — from a clinical perspective – on a particular record there might be some debate. Quality vs severity is one and quality vs timing is another — and that’s simply because severity statements and timing statements are sometimes expressed with adjectives too.
    That said, though, I agree with the author’s final statement that accurate E/M coding relies on “… the correct interpretation requires consistency, verifiable references, a logical argument, and ultimately, medical necessity”.

  2. Amanda says:

    I diasgree with “(b) Don’t forget that a patient can still be asymptomatic but still have a medical complaint. A patient who is “feeling fine” or who has “no complaints” is not receiving a preventive service if the reason the physician wanted the patient to make this appointment was so that the status of their chronic medical problems could be evaluated.”
    We just had a Panacea audit where we were told that even IF they have chronic problems without complaints, and they’ve scheduled a px, it is preventive, BUT you can charge an E/M along with the preventive if they’re prescribing meds for those chronic problems that may be addressed….

  3. Pam says:

    I think that the issue you encountered with your audit may have to do with the way that the provider worded their note. For example, if you have a patient who has diabetes and is being seen for their diabetes but states they are feeling fine and have no complaints, that does not automatically make that visit preventive. If it were not for the fact that the patient has diabetes they would not be in the office today. Therefore, this is not a preventive visit and would not warrant the use of codes 99381-993957. Codes 99201-99215 would be the appropriate codes in this situation.

  4. Kathy says:

    Thank you for your comprhensive response. I had a lot of the same thoughts when I first read this article. I have one question for you regarding counting allergies in ROS vs. PMH. I agree with your statement regarding the “NKDA” and have never counted that as part of the ROS. My question is, when is it appropriate to count an allergy in ROS? Is it when the patient has an allergy to a drug or other substance such as pollen, cat/dog dander, etc.? Or does it need to be related to the HPI in some way, such as patient presents with runny nose, itchy eyes, sneezing, etc. I have my opinion on this, and have debated it with other coders. I would like your professional opinion and if there is an authoritative resource on this, it would be even better.
    The E/M section has so many subjective areas that it is hard to be consistent. For example in MDM using the Marshfield counting system the provider gets credit for personally viewing an image, but what if the same provider also billed for that image (example-chest x-ray). Can you give the extra 2 points AND bill for the professional component of the x-ray? I found in my research, some Medicare carriers say yes you can count it and others say no you cannot because you are already receiving compensation for that service.
    Bottomline, when auditing E/M do your homework and research the Medicare carrier in your area and any other major payers to see if they have guidance on how THEY determine the level of service. They will all tell you that medical necessity trumps all, but of course that is the most subjectve of all the components.
    Thank you again Joan for your very insightful and dead-on rebuttal to the article.

  5. Pam says:

    I had this same issue regarding allergies as I was always told that it is a PMH item and not a ROS. In fact, I attended an E/M coding class put on by our MAC and we were specifically told that allergies are PMH and NOT ROS. However, on our MAC’s website they are this question asked and answered: “Can an allergy be part of the ROS rather than the past history? For example, patient has allergy to penicillin; it causes hives”. Their answer: “Yes”. So it appears that even the MAC’s can’t determine which is correct. I think that you could probably find enough documentation out there to support an argument either way.

  6. Joan Gilhooly says:

    The MAC’s response is absolutely consistent with their statement that “Allergies” in general is not part of ROS! What was in their Q/A was an example of the physician asking the specific SYMPTOMS the patient had when they experienced an allergic reaction to a medication. That is VASTLY different that simply asking the patient whether they’re allergic to medication, latex or something like that.
    For both Pam and Kathy, on this subject of “Allergies” as past medical history vs the “Allergic system” for ROS, the key thing is whether or not the physician has asked a specific question about the symptoms the patient experienced when having an allergic response. It’s very targeted (specific to what happened when the patient responded to that allergen). That’s unlike a patient who presents today with an unknown complaint for which questions are being asked in multiple systems (Eyes, ENT, Respiratory, skin — sometimes even GI) that ultimately lead the physician to determine that the patient is having an allergic response to something.
    The other time I categorize a symptom as “allergic” is when it’s obviously an allergic reaction, but it doesn’t fit clearly in one organ system This past weekend, my known tree pollen spring allergy kicked up and my eyes were really itchy. But that was my eyes as a BODY AREA. Was it the skin around my eyes that was itching? Or was it the conjunctiva and/or corneal that were responding? In this case, since I (as the patient) wasn’t specific — but was instead simply explaining that I was experiencing one of the classic symptoms I get when my tree pollen allergy kicks up, I think in that case, it would be OK to classify the documentation of that symptom as the “allergic system” (as long, of course, that you don’t “double dip” and count that one symptom as “allergic” AND “eyes” or “allergic” AND “skin”.
    The key thing to remember if you’re going to count something as “allergic system” is that you have to have a symptom that the patient is describing that describes their allergic RESPONSE.
    If it helps any, I rarely count the allergic system when I’m auditing. Usually the documentation about allergies is a simple statement that the patient is allergic to “X” (which will always be past medical history”) or that they have a conglomeration of symptoms that when taken together seem to point to the fact that the patient is reacting/has reacted allergically to something. If you’re going to count the “allergic system”, you really have to have documentation of a direct tie of an allergic RESPONSE to a SPECIFIC allergen trigger.
    Hope this helps!

  7. Joan Gilhooly says:

    Assuming that “PX” means preventive medicine service, you and I are still in agreement. If you go back and re-read my response, I specifically said that my hypothetical appointment was a physician requested recheck of the patient’s chronic diseases (usually done quarterly, although in some cases, done every 2-4 months and in some cases twice per year).
    If a patient with chronic diseases comes in for a preventive service, the fact that they have chronic diseases doesn’t change anything. If the patient was there for a preventive service and the physician ALSO worked up the current status of the chronic diseases, the AMA tells us we first must count up everything that is normally done for the preventive and assign that to the preventive code. Only the ADDITIONAL work done to work up the problem(s) can be counted towards a separately reportable problem oriented E/M.
    If they’ve ONLY renewed meds (ie, there wasn’t separate HPI, ROS and exam done above and beyond what’s normally done with a preventive service) for this patient who came in for a preventive service, I don’t think you’ve met the criteria for reporting a separate problem oriented E/M. The AMA is pretty clear that only the additional work that was done can be counted. If you’ve only got a meds renewal for chronic disease meds in a patient who came in for a preventive medicine visit, there isn’t evidence of a separate E/M service

  8. Cheryl Bouschor says:

    Wow! Great dicussion, ladies! I learned a lot here! My hat is off to your knowledge!

  9. Audrey says:

    Question – The patient comes in with their chief complaint, but the diagnosis the doctor lists don’t always match. For example, CC is “I think I have Bronchitis” and the doctor lists back strain, leg pain and cough. I’ve asked and been told that during the visit, he found more complicated things wrong than bronchitis so he listed them instead. So, I ask… Do I go back and ask him to list his 1st DX as related to the CC and the found problems second, even if they are more complicated, or do I file the DX’s as he’s listed them on his notes? I don’t want to be accused of “rearranging DX’s to get a claim paid (fraud)”.

  10. Joan Gilhooly says:

    Just checking to see if additional questions had come up in response to my original response – and realized that I hadn’t responded to Kathy’s question about the data “points” to be assigned when a physician orders a diagnostic test and also reviews the image/tracing of the same test.
    Kathy, if you look at the actual CMS documentation guidelines themselves and go to the Amt/Complexity of data portion of the MDM section, the last “DG” specifically tells you that the physician gets only gets credit for reviewing the image/tracing if it’s a study that has been or will be reviewed by someone else.
    In other words, if the physician is billing the professional component of that study (or the global which includes the professional component), he doesn’t get extra “credit” for having reviewed the image/tracing. That only applies if the study is interpreted by someone else (logically, someone outside of the group).
    I had an attendee at one of my E/M seminars challenge me on that point once a few years back — to the point that she actually wrote to Kit Scalley at CMS to get Kit’s take on the issue (this was obviously before Kit retired). Kit affirmed that my interpretation of this rule in the Documentation Guidelines was correct (the attendee was kind enough to forward Kit’s response to me which is how I know that Kit agreed). So the answer — based on the Documentation Guidelines themselves – is that the physician only gets credit for independent visualization if the formal written professional interpretation is being performed (and billed) by another physician.
    Audrey – on your DX coding question, the ICD9 coding rules tell us that the physician should list as their primary (1st listed) diagnosis the condition that essentially took the most cognitive work for the encounter. The patient may have come in for that cough (the “I think I have bronchitis” complaint), but the doctor is right — that if there are other things he found during his assessment of the patient that were more complicated and essentially took up more of the encounter (from the amount of mental work he needed to do), then that’s the Dx that should be listed first.
    The note, though, should somehow bridge the transition from the patient stated reason for the visit to what the doctor ended up working up. There shouldn’t be an absolute disconnect between what you see in the HPI and what is ultimately recorded in the assessment and plan. Even if the physician didn’t discover the additional problems until he was doing the physical exam, once he found the abnormal finding on the exam, clinically he backtracks and asks the patient HPI and ROS questions about that abnormal finding. Some how there needs to be some kind of transition statement that paints this picture. It could be something like “The patient also complains of…..” Or in the course of the physical exam, I found XYZ which the patient states has been……..” or something along those lines.
    Hope this helps!

  11. Angie T says:

    What if the patient REFUSES to divulge the history. Specifically, we have several cases where sexual history justifies a Medicare’s patient need to been annually, rather than bi-annually but the patient won’t divulge the information. I’ve been erring on the side of caution and just taking the hit financially, but am wondering if this is the right thing to do?

  12. Audrey says:

    Joan, yes! Thank you very much!

  13. Sarah Cruz says:

    I disagree with #2; it is carrier specific whether the provider is penalized. WPS says that we must “code based on the work performed” (talking w/ family, obtaining info from chart). Unfortunately, it is unlikely to get a comprehensive history from the chart or family. What is frustrating for the physicians is that these pts are often more complicated and take additional time.
    If anyone interprets the following differently, please let me know…I would be happy to be wrong on this.
    Q 2. Where does it state that if the history is unobtainable you cannot automatically bill a comprehensive history? Do you automatically have to bill based on a problem-focused history?
    A 2. There is nothing notated in the 1995 or 1997 DG to indicate any level of history is automatic. The physician should document the reason the patient is unable to provide history and document his/her efforts to obtain history from other sources. This could include family members, other medical personnel, obtaining old medical records (if available) and using information contained therein to document some of the history components (past medical, family, social).
    Q 3. We are unable to obtain history as the patient is intubated. Do we have to bill a Not Otherwise Classified (NOC) code?
    A 3. You would only submit a NOC code when you are unable to document any of the history elements. If you are talking to the patient’s family or others to obtain history, document the work performed and code based on the work performed. The use of the NOC (99499) should be very rare.

  14. PJ says:

    I have a question about a new patient visit, My docs do not state preventative. They just say here to establish with no chief complaint. In the assessment and plan they state some chronic conditions the patient may have but they are seeing a specialist for.
    Here’s an example: Hyperlipidemia. Continue low cholesterol, low starch diet. Continue medications. Follow up with cardiologist as previously directed. It says medication reconciliation was done but he didn’t change any of the pt’s meds and pretty much said the same thing for every chronic they had. Would this be considered a preventative? How would you code this? Does the documentation need to be clear that the intent of the visit was preventative?

  15. Jill Holland says:

    How do ADL’s (activities of daily living) count toward PHI and MDM?