Psychiatry Coding & Reimbursement Alert

Question: We have patients provide their chief complaint/reason for visit, history of present illness, review of systems, and past medical, family, and social history on an electronic pad that adds the information to the patient’s medical record for that date of service. When the physician goes into the room, he reviews all of that information with the patient. Can we count everything when determining the level of history for the encounter? 

New Mexico Subscriber

Answer: You can count part of the notes entered by the patient toward the history for the encounter. 

According to the 1995 and 1997 E/M Guidelines, “The ROS [Review of Systems] and/or PFSH [Past, Family, and Social History] may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.” Historically, Medicare contractors and others have interpreted this guideline to mean that the physician or other qualified health care professional under whose name the service is to be billed must document the other parts of the history, including the history of present illness (HPI) and chief complaint. Thus, to be safe, you may not want to count the HPI and chief complaint if they were documented by the patient and then simply reviewed by the provider. The physician must confirm, in his own words, the chief complaint and the HPI within his note.

As noted, ancillary staff or the patient himself can document the ROS and PFSH. As long as the provider reviews the information and notes in his documentation that he reviewed it, you can count those elements toward the history level. 

If, after the physician reviews the information gathered on the electronic pad, he then personally captures the chief complaint and HPI during the patient visit, you can determine the level of history.