Urology Coding Alert

Question: Are there any official coding rules or regulations that state how often a patient's history needs to be updated, especially when I am referring to H&P for coding reasons? I know patients are "new" if they are not seen in three years. Is the history also good for three years?


New York Subscriber

Answer: When your urologist sees a patient in your office, not in the hospital where the interval history is applicable, there are no specific limitations on how often you need to obtain a complete new history for a patient.

From an E/M documentation standpoint for you to report an established patient office visit code--which would apply in this scenario--your urologist must meet two of the three elements of history, physical examination (PE), and medical decision-making (MDM).

While technically, a patient visit could qualify for a code from the 99211-99215 series with only PE and MDM, in urology it is usually the history and MDM that the physician focuses on. That being said, in order for any of the elements of history (history of present illness [HPI]; review of systems [ROS]; and past, family and social history [PFSH]) to qualify for documentation of a given level, there must be evidence that it was either performed again or reviewed and updated.

Note: In the latter situation, if one of the key components of the E/M service is the history, a urologist must personally obtain the HPI. In fact, each time a patient comes into your office your physician must again obtain the HPI. Simply reviewing a previously obtained HPI is not sufficient for documentation of a new HPI during a new encounter. 

But ancillary office personnel such as a physician assistant, nurse, or medical technician can obtain the ROS and PFSH. The urologist may note the findings, add further information, and countersign and date the encounter indicating his review and acceptance of the findings. The physician is not obliged to repeat this part of the history, and during subsequent encounters he may just only need to review the ROS and PFSH from a previous visit and receive credit again for this review.

The urologist should also note the date that your office obtained the most recent ROS and PFSH that he is reviewing. Most urologists try to update the ROS and PFSH every 12 to 18 months to maintain the latest, most accurate medical history.

As long as continuity is reflected in the intervals, there would really be no limitations within the three-year period, if the physician has in fact updated the history each time he sees the patient--assuming the urologist properly documents and references the review as indicated above.