# History Level??



## A_Warren (Aug 5, 2010)

Please help me.  I am trying to code out this history, it is a subsequesnt hospital visit...

" Her chief complain today was "this food is making me choke." This is a 64 year old morbidly obese white female who was admitted with respitory failure, acute on chronic.  When seen today she was sitting out of bed in her chair attempting to feed herself with some modified utensils.  She staes the the consistancy of the food makes her choke, and she is not at all happy about that.  SHe has no trouble breathing.  She has no nausea or vomiting.  She has no pain issues.  She has no cough or chest pain.  The rest of the review of systems was negative apart from what was mentioned above.  Her past medical, surgical, social, and family history were reviewed from the H&P which was dictated on July 17, 2010.  No change to the same. 

Can you please help me break this down.  It is just giving me some severe hangups.  Any help on the break down in much appreciated.  

Thanks! 
Ashley


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## perkins (Aug 5, 2010)

*Help me please*

Hi Ashley, I was told to use 99233 since there was past history, social, and family history were reviewed.


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## perkins (Aug 5, 2010)

*History Level*

Hi Ashley, I m not sure, but I would use 99232.


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## LLovett (Aug 5, 2010)

This is comfortably EPF, since it is inpatient it doesn't require the PFSH but they did list it as well. You could say it is detailed but I think that might be pushing it.


Her chief complain today was "this food is making me choke." This is a 64 year old morbidly obese white female who was admitted with respitory failure, acute on chronic. When seen today she was _sitting out of bed in her chair attempting to feed herself with some modified utensils_.  ContextShe staes the _the consistancy of the food makes her choke,_Mod Factor and she is not at all happy about that. _SHe has no trouble breathing._ Associated Sign/SymptomShe has no nausea or vomiting. _She has no pain issues_.Severity but this might be stretching it She has _no cough _ROS Respor _chest pain_ ROS CV. The rest of the review of systems was negative apart from what was mentioned above. Her past medical, surgical, social, and family history were reviewed from the H&P which was dictated on July 17, 2010. No change to the same. 

Just my take on it,

Laura, CPC, CPMA, CEMC


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## sbicknell (Aug 7, 2010)

I have to disagree on one portion.  Anything that is denied, does not have or stated as no (any negative) is a ROS.  A symptom that the pt does NOT have can not be counted as an Assoc S&S. All of the below is ROS

"She has no trouble breathing(Resp ROS). She has no nausea or vomiting (GI ROS). She has no pain issues (Neuro ROS). She has no cough (Resp ROS) or chest pain (CV ROS)."

I would also be very hesitant to code a 99233 (detailed exam and high complexity MDM) but then we don't know what was documented in the rest of the note.


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## LLovett (Aug 9, 2010)

Sbicknell,

Can you please provide documentation to support pertinent negatives can not be counted as HPI elements?

Thanks

Laura, CPC, CPMA, CEMC


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## sbicknell (Aug 12, 2010)

There are numerous postings on the net on the HPI elements and I have never found one that says what a patient does not have can be counted as an Assoc S&S

I know there were some seminars a while ago that it was being said the Assoc S&S could be stated as a negative. And I disagree and would like to see their support for that statement

If the CC was chest pain, denies SOB. I would not count the "denies SOB" as an Assoc S&S.  The Assoc S&S is to identify what else is going on at the time of the CP. So if the patient does not have something (nothing eles is going on) then there is nothing to be "Associated".


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## tosca2004 (Aug 15, 2010)

*history*

Hi, I've found that the e/m scorecard on Highmark's web site is very helpful. Go to their web site and click on e/m training and print e/m  score cards. The history portion states for a complete ROS their must be 10 or more systems, or some systems with statement "all others negative". You have extended HPI, so I would code this comprehensive. Suzanne


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## sbicknell (Aug 15, 2010)

Be aware that the statement "all other negative" for ROS is not accepted by everyone and is specifically rejected by Texas Trailblazer


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## tosca2004 (Aug 15, 2010)

*history*

Thank you for the info....I was going by CMS guidelines.


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## linc11 (Aug 20, 2010)

Sbiknell, 

In regards to your statement...



> Be aware that the statement "all other negative" for ROS is not accepted by everyone and is specifically rejected by Texas Trailblazer


Could you please tell me where to locate this information?  I've heard this same thing stated elsewhere, however, I'm currently reviewing the Trailblazer Coding and Documentation of Evaluation and Management Services manual and it states under the ROS section that a notation indicating all other systems are negative is permissable. 

Your help would be greatly appreciated!


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## rthames052006 (Oct 7, 2010)

sbicknell said:


> Be aware that the statement "all other negative" for ROS is not accepted by everyone and is specifically rejected by Texas Trailblazer



The Medicare carrier on this is Highmark and they do accept all others negative.


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## sbicknell (Oct 7, 2010)

For me, it is easier to educate the physicans on the documentation than to argue with an auditor

If you go to Texas Trailblazer website and click on the tab on the left for "Policies". Has all the letters and postings From the Desk of the Medical Director

http://www.trailblazerhealth.com/Tools/Notices.aspx?ACTION=search&DomainID=1

Three Magic Words? A Frowning Medicare Contractor’s Perspective 
(1/22/2010)  

“In order to have complete review of systems, they say three magic words: all others negative.”  —Nancy M. Enos (From the January ACP Internist, copyright © 2010 by the American College of Physicians)

The January 2, 2010, edition of ACP Internist contained an article by Stacey Butterfield, titled “Clinicians Crucial to Avoiding Coding Errors.”

The ACP Internist article is about coding Evaluation and Management (E/M) services. The article is informational, well-written and worthy of the few minutes its reading requires. *However, it contains some information about which TrailBlazer Health Enterprises® wishes to caution you. *The purpose of this article is to give praise where praise is due (and in doing so to reiterate the article’s useful information) and to warn you of some items in the article that TrailBlazer SM finds troublesome.

Here are some of the commendable points made in the ACP Internist article:

•It recommends care by coders and billers to understand the clinical services rendered to avoid making senseless, sometimes unknowing, and always costly coding errors. 
•It urges coding involvement by clinicians by accurately communicating, via medical record documentation, the true nature of their medical services. 
•It mentions the importance of medical necessity in coding E/M services. 
•It lists common coding mistakes, including abuse and misuse of modifiers 24 and 25. 
•It points out several caveats with documenting high-level initial E/M services that require three of three key components as well as both comprehensive history and comprehensive physical. 
•It suggests caution in relying solely on electronic E/M code selection. 
•It points out that routine annual physicals are not covered under the Medicare benefit, and that any element of a routine physical must be reported separately (separate from covered E/M services) because the expense of these non-covered services is the patient’s responsibility. 


*The article’s first controversial comment regards coding the complete Review of Systems. The author quotes consultant Nancy M. Enos about using the “all others negative” notation as the basis for deeming a Review of Systems complete. The author further adds “many Medicare carriers frown on the liberal use of the phrase ‘all others negative’ although it is allowed under the CMS 1997 documentation guidelines.” 

Be aware that TrailBlazer is one of the frowning Medicare contractors. We disagree that the CMS 1997 E/M Guidelines sanction the “three magic words” as adequate documentation of a complete Review of Systems. 

Having reviewed the CMS E/M guidelines, discussed this issue with CMS’ central office, and by placing the guidelines’ statement about “all others negative” in context with all other CMS payment and documentation rules, TrailBlazer has concluded the following about documentation and coding a complete Review of Systems:

•Symptomatic systems must be separately documented and may not be documented simply as “positive” or “negative."
•Systems related to the presenting complaint/problem must be separately documented and may not be documented simply as “positive” or “negative.” 
•Asymptomatic systems not related to the presenting complaint/problem may be documented simply as “negative.” 
•A complete Review of Systems requires review of at least 10 systems – positive and/or negative. 
•The statement “all others are negative” is insufficient documentation of a complete Review of Systems for which at least 10 systems are not identified as having been reviewed. *

The second issue of concern in this ACP Internist article regards recommending the use of CPT code 99214 to report an encounter solely for evaluation and management of an uncomplicated new illness without systemic involvement, such as acute otitis media. The author states that making the diagnosis of otitis media meets the standard required of moderate medical decision-making; therefore, with a good history of the present illness, reporting such a service using CPT code 99214 is appropriate. TrailBlazer does not share the author’s opinion on this issue. First, from a medical decision-making point of view, evaluation and management of an uncomplicated acute illness without systemic involvement does not ordinarily involve moderate medical decision-making (as judged by the E/M coding guidelines). Secondly, TrailBlazer would generally not find medical necessity for the work associated with such a service. 

E/M services are inherently complex, difficult to codify and are prone to numerous coding errors. Code them carefully and thoughtfully considering both the work documented and the medical need of the patient.

Minimizing those errors is our shared responsibility. For more information about documenting and reporting E/M services to Medicare, TrailBlazer encourages you to browse our E/M Services Web page often.

(Reference: From the Desk of the Medical Director)


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## A_Warren (Oct 8, 2010)

Hi, 

I am the orig author of this post.  I am trying to find a history level.  My medicare contractor - highmark medicare services, which covers PA, does allow all others negative as a complete review of systems.  But, while I appreciate your input about Trailblazer, could you help me with my issue?  What would you consider this to be for a history, knowing that all others negative, or some statement of the like, does constitute as full review of systems???


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## abc1099 (Oct 11, 2010)

tosca2004 said:


> Hi, I've found that the e/m scorecard on Highmark's web site is very helpful. Go to their web site and click on e/m training and print e/m  score cards. The history portion states for a complete ROS their must be 10 or more systems, or some systems with statement "all others negative". You have extended HPI, so I would code this comprehensive. Suzanne



Would you mind posting the link for this?  I would like to take a look at their score cards.  We use WPS so I am not familiar with Highmark's website.  Thanks.

Ann Campbell, CPC
Cancer & Hematology Centers of Western Michigan


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## jdibble (Oct 12, 2010)

A_Warren said:


> Hi,
> 
> I am the orig author of this post.  I am trying to find a history level.  My medicare contractor - highmark medicare services, which covers PA, does allow all others negative as a complete review of systems.  But, while I appreciate your input about Trailblazer, could you help me with my issue?  What would you consider this to be for a history, knowing that all others negative, or some statement of the like, does constitute as full review of systems???



It does seem that this went off track from your question! 

I would say the history for your note would be *Expanded Problem *- based on the components of the History, since this is an Interval History, the PFSH is not needed although your doctor did document.  The ROS is complete based on Highmark Medicare Services, where I am located also.  The HPI however is not Exteneded - there are not 4 elements there to make it exteneded, so this would be Brief.  A Brief HPI would give you an Expanded Problem Focused History regardless of a complete ROS or PFSH.

So, the History level in this case would be *Expanded Problem Focused*.  As far as the correct CPT code, that would depend on the level of the exam and MDM, so one cannot determine this code without the rest of the note.  For a Subsequent visit you only need to meet 2 for the three components. 

Hope this helps.


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## jdibble (Oct 12, 2010)

abc1099 said:


> Would you mind posting the link for this?  I would like to take a look at their score cards.  We use WPS so I am not familiar with Highmark's website.  Thanks.
> 
> Ann Campbell, CPC
> Cancer & Hematology Centers of Western Michigan



Hi Ann,

the website is www.highmarkmedicareservices.com.  When there, click on the Professional Part B tab on top and then you would click on the Evaluation and Management tab in the left column to get to the page with the score cards.


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## MikeEnos (Oct 12, 2010)

To answer the question:

*HPI *- 3 (Feeding herself - Context ; Food consistency - MF ; N/V - AS)
*ROS *- Comp (unless you don't go by 'all others negative' even though the 1995 guideliness explicity says that it is acceptable)**
*PFSH *- 3

This is Expanded Problem Focused History.  The shame of it is- one more solid HPI brings it to Comprehensive.  They could have easily mentioned the duration (she first noticed this when eating dinner yesterday), timing (it only happens in the morning), quality (it feels sticky in her throat), something.

** 1995 Guidelines (which Trailblazer links to on the main part of their site)
At least ten 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 are negative is permissible*. In the absence of such a notation, at least ten systems must be individually documented.


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