Detailing Patient History Means Higher Reimbursement
Published on Tue Aug 01, 2000
Taking a patients history is probably the easiest component of an evaluation and management (E/M) to document, because both patient and clinical staff can be used to provide the information and documentation. Despite this, auditors are finding that poorly documented history is resulting in E/Ms being downcoded as much as three levels.
Otolaryngologists normally take an appropriate level of history, depending on the condition of their patient, but because they tend to be focused on the patients condition and dont want to waste time on other matters, that history doesnt always end up in the documentation. This may cause no harm to the patient but certainly will hurt the otolaryngologist in the pocketbook, says Arlene Morrow, CPC, a coding and reimbursement specialist in Tampa, Fla.
For example, the otolaryngologist sees a patient who complains of chronic sinusitis. A comprehensive history is taken, but all that is written in the documentation is,
Patient complains of sinus headaches and nasal congestion, occasional post-nasal drip, and rhinorrhea.
Because the documentation contains only a chief complaint and a history of present illness (HPI), but no review of systems (ROS), it could warrant only a problem-focused history, which in turn means only a level one new patient visit can be billed, irrespective of the level of examination and medical decision-making (the other two components of an E/M service).
Note: For established patients, a problem-focused history qualifies for a level-two visit.
On the other hand, had the otolaryngologist documented the patients history as follows below, it would qualify as comprehensive.
Patient complains of sinusitis; symptoms have been present for three years and gotten progressively worse last three months; symptoms seem to worsen during springtime; occasionally patient has increased pain in the sinus area; green drainage from the nose; pain in the front of the face; and fever. Patient has taken antibiotics and antihistamines in the past to relieve these symptoms. No positive personal or family history of allergies. Patient doesnt smoke. Reviewed patient info sheet for other review of systems and past medical history, all other systems negative except those noted above.
A comprehensive history means that it would support either a level-four or level-five new patient visit or consult (99204, 99205, 99244, 99245), as long as the exam and medical decision-making were documented at the same level and there is medical necessity for performing a level four or five. (An established patient visit requires only two of three categories.) A comprehensive history requires an extended chief complaint/history of present illness.
In the history cited above, such elements include: (1) site of chief complaint (sinuses); (2) context (worsening, chronic); (3) associated signs or symptoms (green drainage from nose, pain and fever); (4) timing (gets [...]
