1. The Nuts and Bolts of E&M Coding Part 1 of 3 Key Components of History Presented by: Angie Nolan, CHA, CPC, CPC-I, PCS, RMA HIMS Educator – Banner Medical Group

2. E&M Codes Require Key Components The first Key component is the History which has 4 elements: CC or Chief Complaint HPI or History of Present Illness ROS or Review of Systems PFSH or Past Medical, Family, and Social History

3. What is the CC or Chief Complaint? The CC is defined as a concise statement, usually in the patient’s own words, describing the symptom, problem, condition, diagnosis, or other factors for which the patient is seeking care from the physician or other non-physician practitioner; which is required at all history levels and must be clearly documented in the medical record for every visit. One exception to this is that subsequent hospital visits only require an interval problem focused history be documented in the medical record.

4. What is the HPI or History of Present Illness? The HPI is defined as a chronological description of the development of the patient’s present illness from the first sign or symptom to the present. There are 2 levels of HPI Brief which consists of 1 to 3 elements Extended which consists of 4 or more elements

5. What are the elements of HPI? Location Duration Severity Quality Timing Modifying Factors Context Associated Signs and/or Symptoms

6. Let’s take a look at each element! Location: Where do the patient's symptoms occur? In order to use location, it should be a place on the body that you could point to or touch and that the physician describes as the place where the patient's symptoms occur. Head, shoulders, knees and toes.

7. Let’s take a look at each element! Duration: How long has the patient has these symptoms? It could be short. That is, the patient had them in the middle of last night, the symptoms have lasted for 24 hours, or it could be a longer time, such as longstanding, months, years. Any description about the duration of the length of the patient's symptoms, illness or condition can be used as an element of duration.

8. Let’s take a look at each element! Severity: That is, how bad are the patient's symptoms? Are they getting better or worse, increasing or decreasing? Sometimes a clinician might note the pain scale that the patient is having, such as 9 of 10. The patient might be feeling well or okay.

9. Let’s take a look at each element! Quality: What is the nature of the patient's symptoms? What is it like? What characteristics describe the symptom? Typically this will include colors, such as green, red, or yellowish. It will include a description of the type of pain: burning, stabbing, dull, achy, etc.

10. Let’s take a look at each element! Timing: That is, under what circumstances do the symptom occur? Is it intermittent, continuous, constant, upon awakening, still, or after exercising? Those are the kinds of words, which can be used to describe the timing of a symptom.

11. Let’s take a look at each element! Modifying factors: The modifying factors are any treatments prescribed by a physician or tried by the patient without physician direction, which the patient has used to try and improve their symptoms. It could be that the patient has been on antibiotics already for a week, or that the patient has tried elevating their leg without relief, or that they have tried over-the-counter medications. Aspirin, rest, antibiotics, CABG.

12. Let’s take a look at each element! Context: In order to answer this question, consider in what context the patient's symptoms occur. Did they happen after a motor vehicle accident, after slipping on the ice, or in relation to another illness or surgery?

13. Let’s take a look at each element! Associated signs and symptoms: That is, other findings that the patient presents with, related or unrelated to today's chief complaint. It could be that the patient came in and also complained of fever, weakness, confusion--any other symptom, which the patient describes. We typically think of these elements as positive complaints, but many auditors will use a negative response in associated signs and symptoms.

14. FQA”s Can you use the same element twice? The guidelines do not say yes or no about this. Some coding auditors report that in private communication CMS has told them that they can use the same element twice. That is, they could use hip and leg, or hip and arm, as two elements if they were two different problems described in the HPI. This is not verified in writing and it would be more conservative not to do that.

15. FQA’s Only the billing clinician may document the history of the present illness. Unlike the chief complaint, review of systems, and past family medical and social history where a staff member might document part of the history as long as the physician has reviewed it, the history of the present illness must be documented by the billing provider.

16. FQA’s It is possible to use the status of three chronic diseases in place of the four elements of the history of the present illness. This is especially helpful when treating patients with chronic problems such as diabetes, hypertension, and hyperlipidemia. In this case, specifically document the status of their problems at home in the history section. Here is an example: “I am seeing this patient for follow-up for diabetes. She reports her blood sugars at home to be in 150-200 range. She is checking her sugars after meals. Her current medication are X,Y and Z.” Document the status of at least three of their chronic diseases in place of the four HPI elements. Document one or the other.

17. FAQ’s It is insufficient to simply list their chronic diseases in the history and document the status in the assessment in the plan. The status of their chronic diseases must be documented in the HPI.

18. What is a ROS? The ROS is defined as an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced. There are 3 levels of ROS Problem Pertinent which consists of 1 system (directly related to the presenting problem) Extended which consists of 2 to 9 systems (directly related to the presenting problem and a limited number of additional systems) Complete which consists of 10 or more systems (directly related to the presenting problem plus all additional systems) Per CMS 1995 and 1997 Documentation Guidelines each of those systems with positives or (as it related to the chief complaint) pertinent negatives must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such notation, at least 10 systems must be individually documented.

19. What systems are recognized for a ROS? • Constitutional symptoms (e.g., fever, weight loss) • Eyes • Ears, Nose, Mouth, Throat • Cardiovascular • Respiratory • Gastrointestinal • Genitourinary • Musculoskeletal • Integumentary (skin and/or breast) • Neurological • Psychiatric • Endocrine • Hematologic/Lymphatic • Allergic/Immunologic

20. FAQ’s A ROS obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by: • describing any new ROS information or noting there has been no change in the information; and • noting the date and location of the earlier ROS. The ROS 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. If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history.

21. What is PFSH? Past (Personal) Medical History – a review of prior illnesses or injuries, operations, hospitalizations, medications, ect Family (Medical) History – a review of medical events in the patient’s family that are hereditary or place the patient at risk Social (Personal) History – review of habits such as smoking, drug use, living arrangements, occupation, ect There are 2 levels of PFSH Pertinent which consists of a review of the history area directly related to the presenting problem Complete which consists of a review of 2 or all 3 of the areas

22. FAQ’s A PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by: • describing any new PFSH information or noting there has been no change in the information; and • noting the date and location of the earlier PFSH. The PFSH 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. If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history.

23. Table of History Elements

24. Let’s Re-cap what we discussed today! 4 Elements of History CC HPI ROS PFSH

25. Questions and Open Discussions