Part B Insider (Multispecialty) Coding Alert

History:

Those Who Take a Lousy History Are Condemned to Repent It

Published on Wed Dec 17, 2003

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4 tips on obtaining a great patient history

It only takes a few minutes for your physician to obtain all the details of where the patient's illness came from and what the patient is experiencing. And it should only take you a few minutes to turn this into useful documentation. But if those two things fall into chaos, it can mean hours of aggravation.

Luckily, coding experts offer some tips on obtaining the perfect patient history:

Remember the difference between the history and the exam. Especially when it comes to the review of systems (ROS) portion of the history, the doctors may try to write down things they've observed themselves. "I teach doctors that ROS comes from the mouth, whereas an exam comes from the hands," says Barbara Cobuzzi, president of Cash Flow Solutions in Lakewood, N.J.

"The ROS is always something the patient reports. The physical exam is the observation of the doctor," says Joanne Steigerwald, senior consultant with the Wellington Group in Cleveland. "You can't diagnose a headache by looking at it."

Make sure the physician gets the information down on paper. Often, physicians will ask all the right questions, but they won't write down the answers, says Laura Talbert with Shore Billing & Management in Allen, Md. "They're talking to the patient [while] they're moving the leg around and asking, 'Does it hurt when I do this?' " she says.

Avoid double-dipping. You shouldn't list the same items under more than one area. For example, Cobuzzi says, allergies can fall under either ROS or past family and social history (PFSH). "You can count it once in either place, but you can't double-dip."

Give the patients a form. "The patients can fill out their history as long as the doctor writes down that he reviewed it and is aware of it," Talbert says. "You can have a great questionnaire." The physician can go through the form with the patient and ask the patient to elaborate on her answers, then scribble exam results on the back and fill in a little more information. "There you have a wonderful report."

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