Pediatric Coding Alert

The new Evaluation and Management (E/M) Services, which will be enforced by the federal Health Care Financing Administration starting July 1998, set up rigid guidelines for physicians to follow in coding their services. In the February 1998 issue of PCA, we featured how to determine the medical complexity part of the documentation process. This month we are focusing on the four types of history. Remember, the higher you code, the greater the reimbursement -- but you must have the documentation to back up your code.

The four levels of history are problem focused, expanded problem focused, detailed, and comprehensive. Regardless of level, the history must include some or all of the following: chief complaint; history of present illness; review of systems (ROS); and past, family, and/or social history (PFSH). Here are the required elements for each type of history:

Problem-focused: Brief history of present illness. No documentation of ROS or PFSH is necessary.

Expanded problem-focused: Brief history of present illness, problem-pertinent ROS. No PFSH documentation necessary.

Detailed: Extended history of present illness, extended ROS, pertinent PFSH.

Comprehensive: Extended history of present illness, complete ROS, complete PFSH.

Regardless of the level of history, the chief complaint (CC) must be clearly reflected in the medical record. It is usually stated in the patients or parents words, and describes the reason for the encounter.

Under the new E/M services guidelines, you may include the CC, ROS, and PFSH as part of the description of the history of the present illness, or you can list them separately. If you obtained an ROS and/or PFSH in an earlier encounter, you do not need to rerecord this information providing that you review and update the previous information -- and that there is evidence that you have done so in the medical record. To show you have updated the record, you may describe any new information, and note the date and location of the earlier information.

History of Present Illness

For a brief history of present illness, you must include one to three elements of the list below. An extended history of present illness consists of at least four elements from the list, or the status of at least three chronic or inactive conditions.

Location Quality
Severity Duration
Timing Context
Modifying factors
Associated signs and symptoms

ROS and PFSH

Review of systems (ROS) includes:

Problem-pertinent ROS - only applies to the problems identified in the history of present illness.

Extended ROS - inquires about the problems identified in the history of present illness, and a limited number of additional systems.

Complete ROS - inquires about the systems directly related to the problems identified in the history of present illness, plus all additional body systems. At least 10 organ systems must be reviewed for a complete ROS. All positive or pertinent negative responses from the patient or parent must be documented.

The past, family, and social history (PFSH) includes:

Pertinent PFSH - must review at least one specific item for any of the three history areas.

Complete PFSH - for the following categories of E/M services -- office visits for established patients, emergency department, domiciliary care for established patients, and home care for established patients -- you must document at least one specific item from two of the three areas.

Complete PFSH - for these categories of E/M services -- office visit for new patients, hospital observation services, hospital inpatient services, consultations, comprehensive nursing facility assessments, domiciliary care for new patients, and home care for new patients -- you must document at least one specific item from each of the three history areas.