Patient History Can Boost Level of Service
Published on Sat Jul 01, 2000
Nugget: ED physicians and staff should be encouraged to document history with: history of present illness, past family and social history, and review of systems portion of the patient exam to increase the level of decision-making needed to optimize reimbursement.
The new rules that instruct facility coders to record signs and symptoms on the UB-92 form have opened the door to more accurate reflection of hospital services. This rule will require coders to make even more use of the patient history. Since the history portion of the patient encounter is the only place where a coder can find information about symptoms after the fact, it becomes increasingly important to ensure that the history portion of the exam is taken and used correctly for optimum billing purposes.
For a problem-focused visit, often coded at 99281 (DEF) or 99282 (DEF), the history of present illness (HPI) needs to include the chief complaint, symptoms, and some brief information about the onset of the problem, according to Sue Mote, CPC, director of reimbursement and operations consulting at the Healthcare Practice Enhancement Network in Los Angeles. You only need to meet so many components. If it is a complex visit or a new patient, it will generally include everything. It starts to become more complicated depending on the level of visit.
High-level visits, such as those that might be coded 99284 or 99285, require much more information. In addition to the chief complaint and symptoms, these visits might require a more extensive HPI, as well as information on a past, family and social history (PFSH), and a more complete review of systems (ROS). In emergency medicine, often the most important part of what doctors do for the patient depends on that history, according to Patrick ONeal, MD, emergency department medical director at Dekalb Medical Center in Decatur, Ga. Were taught early in medical training that the majority of diagnoses can be made from the physical and the history without a bunch of tests. And of the two, the history is infinitely more valuable than the physical in most cases.
Document to Boost Decision-making Level
Unfortunately, many doctors do not recognize the value of documenting history, leaving coders without information needed to effectively code claims, Mote notes. Coders may have in their minds the fact that a code could have been used, but the documentation does not support it.
All the history in the world is not enough to justify a high-level claim when the decision-making is not difficult. But if you have a complex case, with complex decision-making, and you skip the history, you cannot support [...]
