Ob-Gyn Coding Alert

Securing the correct history level is easy with this element-by-element study.

You don’t have to be overwhelmed by E/M history levels’ laundry list of requirements. Take each requirement one step at a time, and then use our handy history chart to choose the right level for your patient.

You have four levels to choose from:

- problem-focused
- expanded problem-focused
- detailed
- comprehensive.

When determining the appropriate history level for your E/M codes, consider the following elements.

CC: Clarify Medical Necessity

Every E/M history level requires a chief complaint (CC). According to CPT®, this is a concise statement, usually in the patient’s words, explaining the main reason for the appointment. Look for a symptom, problem, condition or diagnosis. 

Documentation should note specific problems to support medical necessity for the visit. Even if your office asked the patient to return, look for the complaint that prompted the visit.

Example: A patient presents for uterine fibroid assessment, and the provider documents uterine fibroids as her chief complaint.

Bottom line: Look for a complete CC. Payers won’t find “Here for recheck” an acceptable chief complaint.

HPI: Look for These Factors in Patient Timeline

The second E/M history element, history of present illness (HPI), should be an actual chronological description of the patient’s current illness.

Check your documentation for location (example: uterus), quality (e.g., dull pain), severity (e.g., going through four pads in an hour), duration (tumor detected last month), timing (soon after taking the medication), context (while walking quickly), modifying factors (better after sleeping), and associated signs and symptoms (for instance, nausea). 

If you have documentation of one to three of these categories, consider this a brief HPI. Four or more equals an extended HPI.

ROS: Count Systems to Determine Proper Level

For the third E/M history element, review of systems (ROS), the provider either analyzes a questionnaire filled out by the patient or support staff or directly asks the patient questions (or both). Keep in mind, however, that this section does not involve examining or touching the patient.

Red flag: Payers and auditors who smell cloned documentation may hit your practice with fines and refund requests. Patient-completed ROS templates may be OK, but ask providers to make their documentation specific to each patient.

The main purpose of the ROS is to be sure no important symptoms have been missed, especially in areas not already covered in the HPI.

CPT® E/M guidelines list 14 different systems:

- constitutional symptoms (example: weight loss)
- eyes (such as blurred vision)
- ears, nose, mouth, throat (e.g., trouble swallowing)
- cardiovascular (e.g., hypertension)
- respiratory (e.g., shortness of breath)
- gastrointestinal (nausea)
- genitourinary (urine incontinence)
- musculoskeletal (joint pain)
- integumentary (skin and/or breast; example: discolored skin)
- neurological (such as numbness)
- psychiatric (depression)
- endocrine (taking synthetic hormones)
- hematologic/lymphatic (anemia)
- allergic/immunologic (asthma/immunodeficiency).

What to do: If documentation covers only the system directly related to the present illness, this is a problem-pertinent ROS.

Inquiring about the most directly related system as well as a limited number of others (for a total of two to nine) is an extended ROS.

A complete ROS requires inquiring into 10 to 14 of the body systems. If the provider asks about all the systems and only one is showing problems, documenting the problem and “All other systems reviewed and negative” satisfies the complete ROS requirements, unless your payer instructs you otherwise.

PFSH: Decide Scope With These Tips

The final element for you to consider is past, family and social history (PFSH).

Past history refers to the patient’s own medical history, such as previous surgeries. Family history includes medical events in the patient’s family line, such as hereditary diseases that put the patient at risk. Social history reviews the individual’s past and current activities (for example, occupational history or tobacco use).

If the provider asks only about history related to the main problem, this is a pertinent PFSH. 

Depending on the type of E/M service you’re billing, a complete PFSH may require your physician to document reviewing two or three of the history areas. In particular, new patient office visits and consultations require all three areas (past, family and social) for a complete PFSH. If you-re reporting for a higher-level E/M, definitely make sure you’ve covered all three history areas.

Tabulate Your History Level

Example: You have a CC, and medical necessity supports the brief HPI and problem-pertinent ROS the provider documents. Consider this an expanded problem-focused history level.