Primary Care Coding Alert

Study the claim element-by-element to determine correct history level 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: E/M Always Demands 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 arm pain, and the provider documents arm pain as her chief complaint. Bottom line: Look for a complete CC. Payers require documentation for the medical necessity for each individual encounter. 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, says Bill Dacey, MHA, MBA, CPC, in his presentation "E/M Auditing: Regulations vs. Reality" at the 2007 national American Academy of Professional Coders conference in Seattle. The FP usually performs the HPI element. Check your documentation for location (e.g., arm), quality (e.g., dull pain), severity (e.g., taking 8-10 Tylenol daily for pain), timing (how soon after taking the medication), context (while using the arm), modifying factors (better after sleeping), and associated signs and symptoms (aching in the wrist develops after typing at work all day). If you have documentation of one to three of these categories, consider this a brief HPI. Four or more equals an extended HPI. Per the 1997 Documentation Guidelines for E/M services, the status of at least three chronic or inactive conditions may also qualify as 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 physicians to make their documentation specific to each patient. Also, be sure that the FP documents that the ROS was reviewed with the patient by [...]