THE EVALUATION AND MANAGEMENT DOCUMENTATION GUIDELINES FOR LEVELS OF HISTORY

 By Alan Lyons,D.C.,FAFICC

DG means Documentation Guideline

The levels of E/M services are based on four types of history (Problem Focused, Expanded Problem Focused, Detailed, and Comprehensive). Each type of history includes some or all of the following elements:

  a.. Chief Complaint (CC);

a.. History of present illness (HPI);

a.. Review of systems (ROS); and

a.. Past, family and/or social history (PFSH).

The extent of history of present illness, review of systems and past, family and/or social history that is obtained and documented is

dependent upon clinical judgment and the nature of the presenting problem(s).

  

DOCUMENTATION OF HISTORY FOR NEW PATIENT OFFICE VISIT

CHIEF COMPLAINT (CC) (the reason they came today)

The CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor

that is the reason for the encounter.

a.. DG: The medical record should clearly reflect the chief complaint for the following levels of service.

99201 through 99205

  

HISTORY OF PRESENT ILLNESS (HPI)

The HPI is a chronological description of the development of the patient's present illness from the first sign and/or symptom or from

the previous encounter to the present. It includes the following elements:

a.. Location Severity

a.. Duration Modifying factors

b.. Quality Timing

c.. Context Associated signs and symptoms

Brief and extended HPIs are distinguished by the amount of detail needed to accurately characterize the clinical problem(s).

A brief HPI consists of one to three elements of the HPI and documentation, of such, is required for the following levels of service:

99201 and 99202

An extended HPl consists of four or more elements of the HPI or the status of at least three chronic or inactive conditions and

documentation, of such, is required for the following levels of service:

99203 through 99205

  

REVIEW OF SYSTEMS (ROS)

An ROS is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the

patient may be experiencing or has experienced.

For purposes of ROS, the following systems are recognized:

I. Constitutional symptoms (fever, weight loss, etc.) 8. Musculoskeletal

2. Eyes 9. Integumentary (skin and/or breast)

3. Ears, Nose, Throat, Mouth 10. Neurological

4. Cardiovascular 11. Psychiatric

5. Respiratory 12. Endocrine

6. Gastrointestinal 13. Hematologic/Lymphatic

7. Genitourinary 14. Allergic/Immunologic

 

 No ROS is required for the following level of service:

99201 (new patient office visit).

  

A problem pertinent ROS inquires about the system directly related to the problem identified in the HPI. The patient's positive responses and pertinent negatives for the system related to the problem should be documented. A problem pertinent ROS of one system is required for the following level of service:

99202

  

An extended ROS inquires about the system directly related to the problem(s) in the HPI and a limited number of additional systems. The patient's positive responses and pertinent negatives for two to nine systems should be documented. An extended ROS is required for the following level of service:

99203

 

 A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems. At least 10 organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems negative is permissible. In the absence of such a notation, at least 10 systems must be individually documented. A complete ROS is required for the following levels of service:

99204 and 99205

 

 PAST, FAMILY AND/OR SOCIAL HISTORY (PFSH)

The PFSH consists of a review of three areas:

a.. past history (the patient's past experiences with illnesses, operations, injuries and treatments);

b.. family history (a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk); and

a.. social history (an age appropriate review of past and current activities).

For certain categories of E&M services that include only an interval history, it is not necessary to record information about the PFSH, Those categories are subsequent hospital care, follow-up inpatient consultations and subsequent nursing facility care. In addition no PFSH is required for the following levels of outpatient office visit:

99201 - 99202 (no PFSH required)

 

 A pertinent PFSH is a review of the history area(s) directly related to the problem(s) identified in the HPI.

99203 (pertinent PFSH required)

 

a.. DG: At least one specific item from any of the three history areas must be documented for a pertinent PFSH.

 A complete PFSR is of a review of two or all three of the PFSR history areas, depending on the category of the E&M service. A

review of all three history areas is required for services that by their nature include a comprehensive assessment or reassessment of

the patient. A review of two of the three history areas is sufficient for other services.

99204 - 99205 (complete PFSH required)

a.. DG: At least one specific item from two of the three history areas must be documented for a complete PFSH for the following categories of E/M services: office or other outpatient services, established patient; emergency department,' domiciliary care, established patient,' and home care, established patient.

a.. DG: At least one specific item from each of the three history areas must be doca men ted for a complete PFSH for the folIowing categories of E&M services: office or other outpatient services, new patient; hospital observation services; hospital inpatient services, initial care; consultations; comprehensive nursing facility assessments; domiciliary care, new patient; and home care, new patient.

 

FURTHER DOCUMENTATION GUIDELINES FOR HISTORY

a.. DG: The CC, ROS, and PFSH may be listed as separate elements of a history, or they may be included in the description of the history of the present illness.

a.. DG: A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by: Describing any new ROS and/or PFSH information and noting there has been no change in the information; and - Noting the date and location of the earlier ROS and/or PFSH.

a.. DG: The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing orconfirming the information recorded by others.

a.. DG:If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstances which precludes obtaining a history.

  

 The chart below shows the progression of the elements required for each type of history. To qualify for a given type of history all three elements in the table must be met. (A Chief Complaint is indicated at all levels.)

 

DOCUMENTATION REQUIREMENTS

FOR LEVEL OF HISTORY

Chief Complaint Always Required

 

 NEW PATIENT OFFICE VISIT

CPT

HPI

ROS

PFSH

TYPE OF HISTORY

99201

B 1 TO 3

N/A

N/A

Problem Focused

 

99202

B 1 TO 3

PP 1

N/A

Expanded Problem Focused

 

99203

E 4+

E 2 TO 9

P One from any

Detailed

 

99204

E 4+

C 10 TO 14

C One from each

Comprehensive

 

99205

E 4+

C 10 TO 14

C One from each

Comprehensive

 

 

 

ESTABLISHED PATIENT OFFICE VISIT

CPT

HPI

ROS

PFSH

TYPE OF HISTORY

99211

N/A

N/A

N/A

N/A

 

99212

B 1 TO 3

N/A

N/A

Problem Focused

 

99213

B 1 TO 3

PP 1

N/A

Expanded Problem Focused

 

99214

E 4+

E 2 TO 9

P One from any

Detailed

 

99215

E 4+

C 10 TO 14

C One from any two

Comprehensive

 

KEY

HPI History of Present Illness PP Problem Pertinent

ROS Review Of Systems E Extended

PFSH Past, Family, Social History C Complete

P Pertinent

B Brief

FURTHER DOCUMENTATION GUIDELINES FOR HISTORY

a.. DG: The CC, ROS and PFSH may be listed as separate elements of a history, or they may be included in the description of the history of the present illness.

a.. DG:A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:

a.. Describing any new ROS and/or PFSH information and noting and noting there has been no change in the information; and

a.. Noting the date and location of the earlier ROS and/or PFSH.

 a.. DG: The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.

a.. DG: If the physician is unable to obtain a history from the patient or other source, the record should describe the patientís condition or other circumstances which precludes obtaining a history.

 

 

  OLD GUIDELINES FOR EXAMS VALID FROM 1994 TO DECEMBER 31,1997

In 1994, HCFA issued the first guidelines setting the documentation requirements for the different levels of E&M services. These guidelines covered History documentation required elements, Examination documentation required elements, and Medical Complexity documentation required elements. These requirements are significantly different from the new guidelines that took effect on January 1, 1998. In conducting any review of claims submitted prior to 1998 these old documentation requirements should be used as the standard for evaluating E&M services. From the period of time between October 1, 1997 and December31, 1997 either set of standards may be used since this is considered the grace period for the providers to practice using the new guidelines. Outlined below are the standards for the old guidelines and a description of how they differ from the new guidelines.

HISTORY - The old guidelines for documentation of history are very similar to the new guidelines. They vary in two regards. Under the old guidelines for an extended History of Present Illness you could only qualify for an extended HPI by documenting four or more elements of the history. Under the new guidelines, the guidelines are expanded to include three chronic or inactive conditions, or by documenting four or more elements of the history. The second change is in the PFSH. A comprehensive past, family, and social history can be documented by two or three areas depending on the E&M category.