Each visit category and level of service has corresponding documentation requirements.1 Selecting an evaluation and management (E/M) level is based upon 1) the content of the three “key” components: history, exam, and decision-making, or 2) time, but only when counseling or coordination of care dominates more than 50% of the physician’s total visit time. Failure to document any essential element in a given visit level (e.g. family history required but missing for 99222 and 99223) could result in downcoding or service denial. Be aware of what an auditor expects when reviewing the key component of “history.”
Auditors recognize two sets of documentation guidelines: “1995” and “1997” guidelines.2,3,4 Each set of guidelines has received valid criticism. The 1995 guidelines undoubtedly are vague and subjective in some areas, whereas the 1997 guidelines are known for arduous specificity.
However, to benefit all physicians and specialties, both sets of guidelines apply to visit-level selection. In other words, physicians can utilize either set when documenting their services, and auditors must review provider records against both styles. The final audited outcome reflects the highest visit level supported upon comparison.
Elements of History2,3,4
Chief complaint. The chief complaint (CC) is the reason for the visit, as stated in the patient’s own words. Every encounter, regardless of visit type, must include a CC. The physician must personally document and/or validate the CC with reference to a specific condition or symptom (e.g. patient complains of abdominal pain).
History of present illness (HPI). The HPI is a description of the patient’s present illness as it developed. It characteristically is referenced as location, quality, severity, timing, context, modifying factors, and associated signs/symptoms, as related to the chief complaint. The 1997 guidelines allow physicians to receive HPI credit for providing the status of the patient’s chronic or inactive conditions, such as “extrinsic asthma without acute exacerbation in past six months.” An auditor will not assign HPI credit to a chronic or inactive condition that does not have a corresponding status (e.g. “asthma”). This will be considered “past medical history.”
The HPI is classified as brief (a comment on <3 HPI elements, or the status of <2 conditions) or extended (a comment on >4 HPI elements, or the status of >3 conditions). Consider these examples of an extended HPI:
- “The patient has intermittent (duration), sharp (quality) pain in the right upper quadrant (location) without associated nausea, vomiting, or diarrhea (associated signs/symptoms).”
- “Diabetes controlled by oral medication; hyperlipidemia stable on simvastatin with increased dietary efforts; hypertension stable with pressures ranging from 130-140/80-90.” (Status of three chronic conditions.)
Physicians receive credit for confirming and personally documenting the HPI, or linking to documentation recorded by residents (residents, fellows, interns) or nonphysician providers (NPPs) when performing services according to the Teaching Physician Rules or Split-Shared Billing Rules, respectively. An auditor will not assign physician credit for HPI elements documented by ancillary staff (registered nurses, medical assistants) or students.
Review of systems (ROS). The ROS is a series of questions used to elicit information about additional signs, symptoms, or problems currently or previously experienced by the patient: constitutional; eyes, ears, nose, mouth, throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary (including skin and/or breast); neurological; psychiatric; endocrine; hematologic/ lymphatic; and allergic/immunologic. Auditors classify the ROS as brief (a comment on one system), extended (a comment on two to nine systems), or complete (a comment on >10 systems). Physicians can document a complete ROS by noting individual systems: “no fever/chills (constitutional) or blurred vision (eyes); no chest pain (cardiovascular) or shortness of breath (respiratory); intermittent nausea (gastrointestinal); and occasional runny nose (ears, nose, mouth, throat),” or by eliciting a complete system review but documenting only the positive and pertinent negative findings related to the chief complaint, along with an additional comment that “all other systems are negative.”