Part B Insider (Multispecialty) Coding Alert

Published on Fri May 21, 2004 PDF

But it could also lower your E/M levels and reduce reimbursement

Should a physician keep the History of Present Illness separate from the Review of Systems in the patient's chart?

Some experts say yes, because it makes it easier to separate out those elements when documenting an evaluation and management claim. Others say no,  because it may make it harder to pick up elements from one and use them in the other.

"It's unnecessary, but I recommend it," says David McKenzie, director of reimbursement with the American College of Emergency Physicians in Irving, TX. For the coder, it's "easier and faster" to work off a template where the physician has recorded the information.

"There is no reason to keep the HPI in a separate section of the record from the ROS," says Judy Richardson, senior consultant with Hill & Associates in Wilmington, NC. "In fact this might make it difficult for everyone to find all of the required documentation if a payer were to request the records for a visit."

"You can't keep the HPI separate," says Susan Callaway, a coding consultant in North Augusta, SC. "It is active and changes with every encounter." It's better for the physician to record whatever is relevant to the problem, and let the coder code from that. The HPI must be recorded in the physician's note.

McKenzie agrees that "you can draw HPI or ROS elements from anywhere they appear in the chart, and in fact just the ROS can come from a document recorded by ancillary staff as long as the physician references where they were obtained."

If you separate ROS and HPI in the record, the coder may feel limited to looking in the designated section for ROS or HPI information, instead of pulling them out of the chart, says McKenzie. "It could hurt your chances of accurately coding a level of service."