Coding

Learning from “History”

Patient history can be essential to coding choices.

By Paul M. Larson, MBA, MMSc, COMT, COE, CPC, CPMA

This issue’s column deals with history of documentation requirements and some of the confusion surrounding them. The history is an important part of every single patient work-up and directly impacts the possible coding choices and coverage.

It’s important the physician performs some history elements, but other elements require provider confirmation during the visit. The chief complaint determines whether the patient or the insurer is responsible for payment. History of Present Illness (HPI), Review of Systems (ROS), and Past Personal, Family and Social History (PFSH) are factors that determine the level of service. Since we do not know what code will be used at the beginning of an exam, it would be best to take histories with the possibility of an Evaluation and Management (E/M) code 99201-99215 in mind.

Chief Complaint

The Chief Complaint needs to be one the payer recognizes. Medicare does not recognize “routine,” “annual,” or “broken glasses” as valid complaints, but other payers (such as vision plans) might. Patients who present with a non-covered complaint (where nothing else is noted) should be asked for payment at checkout. The chief complaint can be recorded by staff or provider, but is verified by the billing provider.

History of Present Illness

HPI is often begun by staff, but carries a frequently overlooked requirement: performance by the physician. A scribe may record this interaction or the provider can record it personally. HPI notes lacking the physician’s attestation of performance may seriously affect the coding options available for many 99xxx series codes. Codes 92002-92014 do not need an HPI and, therefore, do not have this requirement. However, they don’t fit every visit. As a result, we may need to use the “universal” E/M system.

History directly impacts possible coding choices

Review of Systems

ROS receives intense scrutiny by payers and auditors. EHR with “copy-forward” features have created new charting risks. This feature allows information previously recorded to be “pasted” into new visits. Be sure, if you use these utilities, you review the information for accuracy.

Past Personal, Social, and Family History (PFSH)

The final history element is PFSH. Payers expect more than records of patient medication. You may need to note medical conditions for which the patient has been treated. Social history might include information about a patient’s profession or hobbies and how they use their eyes. Family history is important. Especially if, for example, a patient’s family has a history of glaucoma.

Correct code choice involves more than history. The examination performed, medical decisions medical necessity of the services provided all have an impact.

“Good coding” to all of you! OP

Mr. Larson is an associate consultant at Corcoran Consulting Group. He specializes in coding and reimbursement. Mr. Larson is based in Atlanta.