Identifying History Components--and Noting Sexual Activity--Is Key to Determining E/M Level
Published on Thu Jul 01, 1999
Along with the examination and medical decision-making components, history drives the level of E/M service. Yet coding experts say its the area of the chart thats usually the most confusing to interpret or is under-documented by the ob/gyn. This can have costly consequences.
For example, lack of enough elements in the review of systems (ROS) is one of the quickest ways to get downcoded by auditors. If the auditor removes just one of the elements, you could lose a level of service. Thats why its critical that coders should understand how to correctly identify and count the elements of a patient history as noted in the chart, and then work with the ob-gyn to improve documentation.
But its not as easy as counting one, two, three.
For example, suppose a note on the chart regarding sexual activity stated: sex positive, uses condoms. Would you classify sexual activity as part of a social history or review of systems or both? What do auditors consider as double dipping? Can you count this notation as a problem pertinent to ROS?
Before you can answer these questions correctly, you must understand the four elements of a history as well as the four history types.
Four Elements of a History
1. Chief complaint (CC): This element summarizes, in the patients own words, why she is seeking
medical attention.
2. History of present illness (HPI): This element is a detailed, chronological description from the onset of the sign or symptom to the present, which may include location, quality, severity, timing, context, modifying factors, or any associated signs and symptoms.
3. Past, family and/or social history (PFSH): This element is actually divided into three sub-categories:
Past medical history. A summary of childhood and adult illness or conditions (such as allergies, drug sensitivities, operations, current medications,pregnancy, etc.).
Family history. A listing of hereditary disease,including the health of immediate relatives, their ages, and causes of death.
Social history. Notations regarding psychosocial or personal history such as marital status, diet, sleeping and exercise, caffeine intake, drug and alcohol use,and/or sexual activity.
4. Review of systems (ROS): This last element is an inventory of systems to enable the physician to better analyze the subjective findings that will in turn determine the nature and extent of the examination.
Four Types of Histories
1. Problem-focused history: Consists of a chief complaint (CC) and brief history of present illness (HPI) or problem. This brief history does not have to include the PFSH or the ROS.
2. Expanded problem-focused history: Consists of a CC, brief HPI, and problem-pertinent ROS (one in which the physician inquires about the system directly related to the problem, e.g., the patient is complaining of dysmenorrhea so the physician might [...]
