Ob-Gyn Coding Alert

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 ask about the age at menarche, contraception, the last Pap smear or menstruation, including frequency, type, duration). This expanded problem-focused history does not have to include the PFSH.

3. Detailed history: Consists of a CC, extended HPI, extended ROS, and pertinent PFSH. The documentation for a detailed history should show positive and negative responses for two to nine organ systems. Also, one of the three histories in PFSHeither past, family or socialmust be documented.

4. Comprehensive History: Consists of CC, extended HPI, complete ROS, and complete PFSH. The physician must review and document positive and pertinent negative responses for at least 10 organ systems. A comprehensive history must include documentation of at least two of the PSFHs for established patients and all three histories for a new patient, a consultation or an admit.

Where to Count Notation of Sexual Activity?

Two coders we spoke to said they would count it under the PSFH as past social history, rather than a problem-pertinent ROS.

But another coder, Linda Sciulli, BS, RN, EMT-P, CPC, of the University of Pittsburgh Physicians, says she would first question the context of the notation by asking herself, Is using condoms or being sexually active a sign or symptom related to the abdominal pain (or whatever sign or symptom brought the patient to the physician)?

Note: A sign is something that can be observed by the physician. A symptom is something that the patient experiences and must describe.

If the answer to that question is yes, Sciulli believes it should be counted as a problem-pertinent ROS. Her rationale is that the ROS is an inventory of the body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced and is related to the chief complaint.

Peggy Breiner, CCS, a senior consultant for the Coding, Compliance and Education Division of QuadraMed Corporation, a healthcare information company, says that the element could fit under either ROS or social history, but not both. Her opinion is based on Mosbys Physical Examination Handbook, published by Harcourt Health Care Publishers in St. Louis.

In this publication, one element of an endocrine ROS for a female is: MensesOnset, regularity, duration and amount of flow, dysmenorrhea, last period, intermenstrual discharge or bleeding, itching, date of last Pap smear, age at menopause, libido, frequency of intercourse, sexual difficulties, infertility.

But sexual history also appears in this publication under social history: Sexual historyConcerns with sexual feelings and performance, frequency of intercourse, ability to achieve orgasm, number and variety of partners.

As you can see, coders with a good understanding of the elements that make up the history component of a patient encounter can more easily resolve any uncertainty in the physician documentation. This understanding also will provide valuable information regarding current coding selections and may allow coders to assist the physician in improving documentation to reduce under- and, sometimes, overcoding.