billing & coding
is the first in a series on evaluation and management coding.
New Year seems like a perfect time to hone our coding skills. Before you determine
the level of the evaluation and management service you provide, you must determine
the level of each of the following three key components: history, examination and
decision making. This is the first in a series of articles on determining the appropriate
levels of the three key components of evaluation and management services. This month, we'll focus on history.
History of Present Illness(HPI)
Review of Systems (ROS)
Past, Family and Social
Associated signs and symptoms
Constitutional symptoms (fever, weight loss)
Ears, mouth, nose and throat
Integumentary (Skin and/or breast)
status/cause of death
relating to the HPI
Use of drugs,
When determining the history level, consider these
1. Chief complaint and history of the
2. Review of systems
3. Past, family and/or social
The first element, or chief complaint,
is the patient's reason for the visit, often recorded in his own words. Describe
the history of this presenting illness (HPI) by location, quality, severity, timing,
context, modifying factors and associated signs and symptoms.
The second element, the review of systems
(ROS), is important for differential diagnoses and often contributes to baseline
examination data. When you document any of the 14 systems in ROS, include the signs
and symptoms experienced by the patient (see the chart below).
The third element to the history has
three components: the patient's past history, the patient's family history and the
patient's social history (see the "History Elements" chart below).
Choosing the level
The chief complaint, nature of the presenting
problem and new or established status often contribute to the amount of history
you gather. The information you document in the medical record determines the level
The table below serves as a reference
tool for efficient history level determination. Your documentation must satisfy
all the require- ments for each history level to claim that level. For example,
if you document the chief complaint and one to three elements of the HPI, then you
have a problem-focused history. If you document the chief complaint, one to three
elements of the HPI and one ROS, that's an expanded, problem-focused history. A
detailed history must include at least four elements from the HPI, at least two
ROS and at least one item from one area of the patient's past, family or social
Use the tables here in conjunction
with your medical record to determine the level of history efficiently. Avoid guessing,
which will lead to under- or over-coding.
Level of History
Expanded Problem Focused
1 area PFSH
3 areas PFSH for new for established patient
DR. MACK IS DIRECTOR
OF CLINICS AT THE OHIO STATE UNIVERSITY COLLEGE
OF OPTOMETRY. SEND E-MAIL TO CMACK@OPTOMETRY.OSU.EDU.
Optometric Management, Issue: January 2007