American College of Physicians: Internal Medicine — Doctors for Adults ®

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How to more accurately document patient history

From the March 2000 ACP–ASIM Observer, copyright 2000 by the American College of Physicians–American Society of Internal Medicine.

By Brett Baker

Q: What role does the history I obtain from a patient play in my selection of a level of evaluation and management (E/M) service?

A: Physicians' Current Procedural Terminology (CPT) 2000 identifies history, examination and medical decision-making as the key components in selecting a level of E/M service.

CPT 2000 recognizes four types of history for E/M service codes. A history can be:

  • problem-focused;
  • expanded problem-focused;
  • detailed; or
  • comprehensive.

Each type of history includes some or all of the following elements:

  • chief complaint (CC);
  • history of present illness (HPI);
  • review of systems (ROS); and
  • past, family and/or social history (PFSH).

You should use your clinical judgment and the nature of the presenting problem to determine the extent of the history of present illness, review of systems and past, family and/or social history.

The chart on this page shows the progression of the elements required for each type of history. All three elements in the table must be met to qualify for a given type of history. The CC is indicated at all levels.

Q: What should I document regarding the history of present illness part of patient history to comply with HCFA's documentation guidelines for E/M services?

A: Medicare issued documentation guidelines for E/M services in 1994 that provided guidance for documenting general multi-system examinations. In 1997, Medicare expanded the guidelines to include 10 single-organ-system examinations. Medicare is currently working with the physician community to simplify the 1997 guidelines, which have been criticized as too onerous. Physicians can use either the 1994 or 1997 guidelines until HCFA releases new guidelines, which should be more acceptable to physicians.

Both the 1997 and 1994 E/M guidelines state that history of present illness is a chronological description of the development of the patient's present illness from the first sign and/or symptom, or from the previous encounter to the present encounter. It includes the following elements:

  • location;
  • quality;
  • severity;
  • duration;
  • timing;
  • context;
  • modifying factors; and
  • associated signs and symptoms.

According to the 1994 guidelines, a brief history of present illness consists of one to three elements, while an extended history of present illness consists of four or more elements. You should describe these elements in the medical record.

According to the 1997 guidelines, a brief history of present illness consists of one to three elements (identical to the 1994 guidelines), while an extended history of present illness consists of at least four elements, or the status of at least three chronic or inactive conditions. You should describe these elements in the medical record.

You may determine the extent of the history of present illness by asking questions such as:

  • Where does it hurt? (location)
  • How is the pain incapacitating? (severity)
  • Does it increase in the evening? (timing)

Q: The history of present illness elements listed in the E/M guidelines (location, severity, timing, etc.) appear to pertain to patients' acute problems. What are physicians expected to document regarding history of present illness of a patient with a chronic or inactive condition?

A: The phrase in the CPT 2000 definition of history of present illness that covers the monitoring of chronic or inactive conditions is "from previous encounter to the present." Also, the 1997 E/M guidelines specifically refer to chronic conditions when discussing an extended history of present illness. Although you will not necessarily touch on the same elements in the guidelines that fit more closely with an acute problem (location, quality, severity, etc.), you should ask others questions to determine whether your history of present illness for a patient with a chronic condition is brief or extended. Examples of such questions are:

  • Are your symptoms recurring?
  • Are you sticking to your medication regimen?
  • Has your blood sugar been normal?

The guidelines fail to spell out specific elements or questions relating to chronic or inactive conditions, so you should ask what you feel is most appropriate under the clinical circumstances.

The revised documentation guidelines proposed by the AMA, which reflect input from specialty societies including the College, contain more specific guidance regarding chronic or inactive conditions in the history of present illness section. However, HCFA is still assessing the proposed guidelines, so the 1997 and 1994 guidelines are still in effect. The 1994 and 1997 guidelines can be downloaded from the HCFA Web site at www.hcfa.gov/medicare/mcarpti.htm.

Q: Can I consider the time that I spend counseling a patient's family member and/or other care decision-makers when deciding on a level of E/M service?

A: Before answering that question, it is helpful to review the criteria that determine when a physician can choose a level of service based on time spent counseling.

CPT 2000 states that time spent with a patient can be the key factor in selecting a level of E/M service when counseling and/or coordination of care accounts for more than 50% of the encounter. Physicians should use face-to-face time in the outpatient setting and floor/unit time in the inpatient setting. Select a level of service by determining the "typical time," which is assigned to most of the E/M service codes, that corresponds to the amount of time that you spent with the patient.

CPT 2000 defines counseling as "a discussion with a patient and/or family concerning one or more of the following:

  • diagnostic results, impressions, and/or recommended diagnostic studies;
  • prognosis;
  • risk and benefits of management (treatment) options;
  • instructions for management (treatment) and/or follow-up;
  • importance of compliance with chosen management (treatment) options;
  • risk factor reduction; and
  • patient and family education."

The following example of an established patient office visit helps illustrate the CPT requirements. You spend 20 minutes of a 30-minute face-to-face encounter counseling a patient. You would qualify to bill CPT code 99214 because the 30 minutes of face-to-face time exceeds the "typical time" of 25 minutes. You could bill CPT code 99214 regardless of the extent of history, examination and medical decision-making.

Regarding time spent counseling a patient's family member or decision-maker, Medicare recognizes time a physician spends counseling a family member and/or other care decision maker only if the patient is present. Time spent counseling without the patient present cannot be used as the key factor in determining which level of E/M service to bill. As you may have noticed, Medicare's policy of requiring the patient to be present is more restrictive than the CPT 2000 definition of counseling.

You should exclude the time you spend counseling family and/or other care decision-makers when the patient is not present if you are using counseling to determine the level of service billed. Of course, Medicare recognizes the time a physician spends counseling a patient directly.

Q: Does Medicare make any exception to the requirement that a patient must be present for time spent counseling a family member or other caregiver?

A: Medicare makes one exception to this requirement when a physician is providing critical care to a patient. The exception states that time involved with family members or other surrogate decision-makers, whether to obtain a history or to discuss treatment options (as stated in CPT 2000), may be counted toward critical care time only when:

(a) The patient is unable or incompetent to participate in giving a history and/or making treatment decisions;

(b) The discussion is absolutely necessary for treatment decisions under consideration that day; and

(c) All of the following four elements are documented in the physician's progress note for that day. They are:

  • the patient was unable or incompetent to participate in giving history and/or making treatment decisions, as appropriate;
  • the necessity of the discussion (e.g., "no other source was available to obtain a history" or "the patient was deteriorating so rapidly I needed to discuss treatment options with family immediately");
  • the treatment decisions for which the discussion was needed; and
  • the substance of the discussion as related to the treatment decision.

HCFA has sent a memorandum (B-99-43) to its Medicare carriers informing them of these instructions. If you want more information, HCFA memorandum B-99-43 can be found on the agency's Web site at www.hcfa.gov/pubforms/transmit/pmemos.htm.

Brett Baker is a third-party payment specialist in the College's Washington Office. If you have questions on third-party payment or coding issues, call him at 202-261-4533, send a fax to 202-835-0441, or send an e-mail to bbaker@acponline.org.

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