Does your staff know what is involved in taking a complete history from a patient?
Each patient encounter includes three key components: the history, the physical examination, and the medical decision making. Determining the level of service for a patient encounter requires documentation of all three components for new patients and two out of three for established patients.
A patient’s history is the first component and is one that often determines your reimbursement. A patient’s medical history should consist of a chief complaint, history of present illness (HPI), review of systems, and past family and social history. This must be documented each time a patient has a visit with the rheumatologist.
Chief Complaint: The chief complaint is a brief statement describing the symptom, problem, the condition for which the physician recommended return, or other reasons for the encounter. The chief complaint is usually stated in the patient’s words. The chief complaint must be listed in each patient’s history. Without a chief complaint listed, the visit could be considered not medically necessary. The chief complaint can be taken when the patient is scheduling the visit. It simply has to be notated in the patient’s medical record.
History of Present Illness: The HPI is the chronological description of the patient’s complaint from the first sign or symptom to the present. It is required for all levels of history and, therefore, all levels of service. There are four types of history: problem-focused, expanded problem-focused, detailed, and comprehensive. Rheumatology practices should report the level that best reflects the documentation. There are eight elements of the HPI that are needed to obtain the correct level of the history. (See Table 1, p. 7.)
The problem-focused and expanded problem-focused histories require that the provider document one to three elements of the HPI. Detailed and comprehensive histories require documentation of four or more elements of the HPI. Unlike the other parts of the patient history, the chief complaint and HPI must be documented by the physician or nonphysician provider reporting the service.
Table 1: The Eight Elements of HPI
- Location: Where on the body is the problem?
- Duration: How long has the problem been there?
- Severity: Is the pain minor, moderate, or severe?
- Quality: Describe the quality of the symptom.
- Context: Are the symptoms getting better or worse?
- Modifying factor: What has the patient done to make it better?
- Associated signs and symptoms: Are there any other signs associated with the main problem?
- Timing: When do the symptoms begin?
Review of Systems: The review of systems (ROS) is a series of questions that helps identify signs and/or symptoms that the patient may be experiencing or has experienced.
The following systems will be recognized as part of the ROS: constitutional symptoms (e.g., fever, weight loss, vital signs); eyes, ears, nose, mouth, and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary (skin and/or breast); neurological; psychiatric; endocrinological; hematologic/lymphatic; and allergic/immunologic.
The ROS can be reported and documented by the patient, nurse, or ancillary personnel, but the physician or nurse must sign off and date the form to indicate that he or she went over the information with the patient.
There are three types of ROS:
- Problem-pertinent ROS: Your documentation must show the patient’s positive responses and pertinent negatives for the system related to the problem identified in the HPI.
- Extended ROS: Your documentation must show the patient’s positive responses and pertinent negatives for two to nine systems related to the problem or problems identified in HPI.
- Complete ROS: Your documentation must show that at least 10 organ systems have been reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least 10 systems must be individually documented.
Past, Family, and Social History: The last section of the history is the past, family, and social history (PFSH). A past history includes past experiences with illnesses, operations, injuries, and treatments. The family history reviews medical events in a patient’s family, including diseases that may be hereditary or place a patient at risk. Recording a patient’s social history includes an age-appropriate review of past and current activities.
For a new patient, all three indicators of the PFSH will have to be notated, and—for an established patient or consultation only—two have to be met to get the highest level of the PFSH. If there is no change, documentation from a patient’s previous visit is acceptable to notate in the file as “no changes” since the last date the original PFSH was documented.
Understanding how to correctly document the patient’s history will put you on the right path in receiving the correct coding level for your visits. If you have questions about this matter, contact the ACR’s professional coding specialist Melesia Tillman, CCP, CPC at (404) 633-3777, ext. 820 or via e-mail at [email protected].
