The information provided here applies to Medicare coding. Be sure to check with your Medicare Administrative Contractor (MAC) for additional information and clarification on these and other items. You should also contact your local insurance carriers to determine if private insurers follow Medicare's lead on all coding matters.
Documentation of a Proper E&M History
Does the visit really need a chief complaint in the documentation? I get asked this all the time. The resounding answer is yes. Both the 1995 and 1997 Evaluation and Management (E&M) guidelines state, “The medical record should clearly reflect the chief complaint.” The term “chief complaint” was defined in the 1995 E&M Guidelines as, “a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter.” The definition was expanded by the 1997 E&M Guidelines with the addition that the chief complaint (CC) be, “usually stated in the patient’s own words.” Documentation starts with the “why” of the office visit, or the initial visit in the hospital. The CC and subsequent History of Present Illness (HPI) set the stage for subsequent exams and workups of a patient and his or her illness.
These two critical areas of documentation state the patient’s view. It is from this point that the rest of the note evolves. It is not hard to see the significance of documentation that reflects a rash on a patient’s hand versus a rash that has been on their hand for two weeks, now spreading up their arm with increasing redness and tenderness. The Review of Systems (ROS) and Physician Exam (PE) may be significantly different in intensity based on the additional information contained in the record.
Another example I frequently see of documentation listed under CC and HPI is “needs refills.” The 1997 Guidelines state the CC is usually in the patient’s own words. Note the word “usually.” In this instance, the patient is most likely in for follow-up related to their chronic illness. As a result, their chief complaint would be that treatment and management of the existing illness. The HPI which 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,” would document any changes in the chronic illness since the patient’s last visit. The story of the patient’s problem is being told.
With only two levels of HPI scored for documentation, the difference in the amount of “detail needed to accurately characterize the clinical problem(s)” varies. A brief HPI is warranted with only one or two elements documented if the patient’s illness is stable. However, if the patient is having problems or has multiple stable illnesses then answers to a number of questions may be needed. What is wrong? How long has it been a problem? How bad is it and what makes it better or worse? Answers to these and other questions will give you the four HPI elements needed in documenting an extended history of the present illness or problem.
After documentation of the HPI, the ROS is next. Asking questions about systems directly related to the problem identified by the HPI and more are needed. Clear documentation of the patient’s problem, its history and severity will flow easily in to the documentation. Each section of documentation is based on information gathered from the prior section.
This completes the discovery aspect of your verbal interaction with the patient. Your documentation should reflect what is wrong with the patient and other items that you deem necessary to your clinical assessment based on your conversation with the patient. The “story” of this patient’s history section is complete.
One note of caution: using pre-populated templates for your chart documentation can be problematic. Documentation in a patient’s chart should reflect what is needed for that patient, for that day, and for their set of complaints. Entering an entire completed section of information by cutting and pasting or by pulling information forward does not show the unique nature of that patient. I cannot tell you how many charts I audit where the ROS is contradicted by other parts of the chart. My assumption is a cloned ROS was entered into that record. Who knows if the questions were actually asked, but it is an incorrect and inaccurate section of documentation with potentially a significant financial impact. Documentation must be specific to each patient encounter.