Looking Beyond the Labels – HISTORY
By Charla Prillaman, CPCO, CPC, CPC-I, CCC, CEMC, CPMA
In February, we examined how “labels” might cause an incorrect count of organ systems examined if an auditor doesn’t take care to read the details beyond the labels.
For purposes of this discussion we will assume that the examination and complexity of MDM meet the proposed new patient billing level and that level we are auditing requires a detailed history. I have rarely, if ever, seen medical record documentation that includes a header or label reading “History”. Instead I see the sub-components of the history with labels – CC, HPI, ROS, Past Hx, Surgical History, Family History, and Social History. What a recipe for confusion – label the sub-components and determine the history level on the whole!
A detailed history (for a new patient) requires a Chief Complaint, 4 History of Present Illness items, 2-9 systems reviewed and 2 of past, family, and/or social history.
Beginning with chief complaint, the label is usually “CC” or “Reason for Visit”. The information is often recorded in the patient’s words. In my experience the most common word trap occurs when this information is populated from the scheduling module. An E/M level should not be based on information populating from a scheduling module. Generally, I advise that the scheduling module not populate information into the progress note. It can be confusing to an auditor who encounters medical record documentation with a chief complaint populated from the scheduling module and another chief complaint recorded by the provider.
Moving to the HPI section, some formats provide the descriptors found in the Documentation Guidelines for Evaluation and Management Services (Location, Duration, Severity, Quality, Timing, Context, Modifying Factors, and Associated Signs/Symptoms) and the provider is expected to select the descriptor filling in the information. Other formats produce a narrative paragraph where this information is included. If the provider says the patient has severe pain under the label “timing” – audit the information and not the label.
What about responses to questions about the patient’s perception of their signs/symptoms? These are review of systems (ROS) wherever they appear in the history section. In fact, they are often included in the HPI section of the note. There is no expectation that the provider must record them twice. Only that one piece of information is not counted twice.
Review of Systems can be a separate section and can even be a patient completed document. Count all the information to discover about which systems inquiry was made. Sometimes a provider may make an entry under the ROS label that says the information is found in the HPI section. Does this count? Yes. To give proper credit, the auditor gathers all the information.
And finally the Past, Family and Social History (PFSH) section. Commonly, PFSH is found under the appropriate label, but always check the HPI section for family and social history, too. Especially for those written in a narrative fashion. It is not uncommon to find that information there.
When teaching auditing, I usually tell the learners to consider history as a bucket into which the provider puts the CC, HPI, ROS, and PFSH. If those sub elements appear in the note “out of order” it is the auditor’s responsibility to assign the right credit to arrive at the documented level of history. The best auditors always look beyond the label!