Radiology Coding Alert

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 uterine fibroid assessment, and the provider documents uterine fibroids as her chief complaint.

Bottom line: Look for a complete CC. Payers won't find "Here for recheck" an acceptable chief complaint.

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.

Check your documentation for location (example: uterus), quality (example: dull pain), severity (example: limited disease process), duration (example: tumor detected last month), timing (example: soon after taking the medication), context (example: while walking quickly), modifying factors (example: better after sleeping), and associated signs and symptoms (example: nausea).

If you have documentation of one to three of these categories, consider this a brief HPI. Four or more equals an extended HPI.

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 providers to make their documentation specific to each patient.

The main purpose of the ROS is to be sure no important symptoms have been missed, especially in areas not already covered in the HPI, says Rebecca Parker, MD, FACEP, president of Team Parker LLC, a coding, billing and compliance consulting firm in Lakewood, Ill.

• constitutional symptoms (example: weight loss)
• eyes (example: blurred vision)
• ears, nose, mouth, throat (example: trouble swallowing)
• cardiovascular (example: hypertension)
• respiratory (example: shortness of breath)
• gastrointestinal (example: nausea)
• genitourinary (example: urine incontinence)
• musculoskeletal (example: joint pain)
• integumentary (skin and/or breast; example: discolored skin)
• neurological (example: numbness)
• psychiatric (example: depression)
• endocrine (example: taking synthetic hormones)
• hematologic/lymphatic (example: anemia)
• allergic/immunologic (example: immunodeficiency).

What to do: If documentation covers only the system directly related to the present illness, this is a problem-pertinent ROS.

Inquiring about the most directly related system as well as a limited number of others (for a total of two to nine) is an extended ROS.

A complete ROS requires inquiring into 10 to 14 of the body systems. If the provider asks about all the systems and only one is showing problems, documenting the problem and "All other systems reviewed and negative" satisfies the complete ROS requirements, unless your payer instructs you otherwise.

Example: You have a CC, and medical necessity supports the brief HPI and problem-pertinent ROS the provider documents. Consider this an expanded problem-focused history level.