Physician’s Coding Strategist
Mine the patient history for vital chart data
Better documentation means better coding
Properly documenting a patient’s history is fundamental to correct evaluation and management coding. Here are some tips from Brett Baker, a coding and reimbursement expert for the American College of Physicians-American Society of Internal Medicine, on what to do and not do when documenting a patient’s medical history.
First, it’s important to remember that besides the data gathered from the medical exam and the physician’s decision-making skills, the level of service selected is primarily influenced by the information gathered when taking the patient’s health history, says Baker.
The CPT 2000 recognizes four types of history for E/M service codes. A history can be:
• problem-focused;
• expanded problem-focused;
• detailed;
• 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);
• 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," advises Baker.
In documenting the history of a present illness physicians can use either the 1995 or 1997 E/M guidelines until HCFA releases a new set of instructions. Both the 1997 and 1995 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 or symptom, or from the previous encounter to the present encounter. It includes the following elements:
• location;
• quality;
• severity;
• duration;
• timing;
• context;
• modifying factors;
• associated signs and symptoms.
"According to the 1995 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," says Baker. "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 1995 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. Baker also advises describing these elements in the medical record.
The following questions are good for determining the extent of the history of present illness:
• Where does it hurt? (location)
• How is the pain incapacitating? (severity)
• Does it increase in the evening? (timing)
The history of present illness elements listed in the E/M guidelines (location, severity, timing, etc.) generally pertain to patients with acute problems. For documenting the history of present illness of a patient with a chronic or inactive condition, 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 other questions to determine whether your history of present illness for a patient with a chronic condition is brief or extended," he says. Sample questions could include:
• Are your symptoms recurring?
• Are you sticking to your medication regimen?
• Has your blood sugar been normal?
Since the current two sets of guidelines don’t spell out specific elements or questions relating to chronic or inactive conditions, Baker says you should just ask what you feel is most appropriate under the clinical circumstances.
Many practitioners are not sure if the time that they spend counseling a patient’s family member or other care decision makers can be considered when deciding on a level of E/M service.
"Before answering that question, it helps to first review the criteria determining when a physician can choose a level of service based on time spent counseling," recommends Baker. CPT 2000, for instance, states that time spent with a patient can be the key factor in selecting a level of E/M service when counseling or coordination of care accounts for more than 50% of the encounter.
Baker’s advice is to select a level of service by determining the "typical time" assigned to most of the E/M service codes that corresponds to the amount of time you spent with the patient.
CPT 2000 defines counseling as a discussion with a patient or family concerning one or more of the following:
• diagnostic results, impressions, or recommended diagnostic studies;
• prognosis;
• risks and benefits of management (treatment) options;
• instructions for management (treatment) or follow-up;
• importance of compliance with chosen management (treatment) options;
• risk factor reduction;
• patient and family education.
Here’s an example. If you spent 20 minutes of a 30-minute face-to-face encounter counseling an established patient during an office visit you would qualify to bill CPT code 99214 because the 30 minutes of face-to-face time exceeds the "typical time" of 25 minutes, says Baker. "You could bill CPT code 99214 regardless of the extent of history, examination, and medical decision making."
Then there is the issue of 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," he notes. Time spent counseling without the patient present cannot be used as the key factor in determining which level of E/M service to bill.
Here’s something to remember: Medicare’s policy of requiring the patient to be present is more restrictive than the CPT 2000 definition of counseling. As such, Baker recommends excluding 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 also recognizes the time a physician spends counseling a patient directly," he adds.
An exception
Medicare makes one exception to the requirement that a patient must be present for time spent counseling a family member or other caregiver when the physician is providing critical care. The exception states that time involved with family members or other surrogate decision makers, whether to obtain a history or to discuss treatment options may be counted toward critical care time only when:
1. The patient is unable or incompetent to participate in giving a history and/or making treatment decisions.
2. The discussion is absolutely necessary for treatment decisions under consideration that day.
3. All of the following four elements are documented in the physician’s progress note for that day:
• the patient was unable or incompetent to participate in giving history 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;
• the substance of the discussion as related to the treatment decision.
HCFA memorandum B-99-43 to its Medicare carriers provides them with these instructions. For a copy of the memo, go to www.hcfa.gov/pubforms/transmit/memos/comm_date_dsc.htm.
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