Published 10/1/2007
Margaret M. Maley BSN, MS

Make documentation problems history

An easy guide to documenting the history of present illness

Unfortunately, few orthopaedic surgeons enjoy learning how to code evaluation and management (E&M) services. A significant portion of practice revenues, however, can be attributed to E&M services. Neglecting the proper documentation and coding of these encounters is a common and costly mistake.

Each patient encounter (e.g. new patient visit, established patient visit, consultation) 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 either two of these three components, or of all three components, depending on the category of service.

Work that is done must be justified by the patient’s diagnoses. Documentation of this work in the patient’s medical record determines the level of service reported. An article covering the entire scope of E&M coding would be a daunting read and perhaps a bit of a snore. So this article will focus on only one part of E&M documentation: the history of present illness.

Patient history
Because most of the patient history is typically documented by someone other than the physician, this aspect of E&M coding generally gets little attention. In many practices, the patient history is recorded on a form completed by the patient. The review of systems, past family history, and social history can be reported and documented by the patient, nurse, or ancillary personnel. When the physician or non-physician provider (NPP) reporting the service reviews the form, he or she should sign and date it. In the dictation, the physician or NPP should state that the form was reviewed with a brief line, “I reviewed the history form filled out by the patient on Sept. 4, 2007.” This part of the history does not need to be redictated but it must be retained in the patient’s medical record.

The chief complaint (CC) and history of present illness (HPI), however, are different from the rest of the components in the patient history. Reporting and documenting the CC and HPI must be done by the physician or NPP reporting the service.

In 1997, the American Medical Association and the Centers for Medicare and Medicaid Services (CMS) jointly developed E&M documentation guidelines. (The complete guidelines can be found on the CMS Web site, www.cms.gov; type “documentation guidelines” in the search box.) These guidelines clearly state that the physician or NPP must document the CC and HPI. CMS recently restated this decision.

Chief complaint
The CC is a brief statement describing the symptom, problem, condition, physician recommended return, or other reasons for the encounter. The chief complaint is usually stated in the patient’s words.

History of present illness
The history of present illness 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, for all levels of service.

The four types of history are problem-focused, expanded problem-focused, detailed, and comprehensive. The one that is reported depends on the documentation. The eight elements of the HPI are listed in Table 1.

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.

Orthopaedic surgeons typically document three elements of the HPI in a single sentence: “Mary Smith comes in today; she has a 3-month history of moderate pain in the right knee.” Such documentation is not time-consuming.

Remember, the CC and HPI—unlike the other parts of the patient history—must be documented by the physician or NPP reporting the service. Taking a few moments to review the elements in Table 1 will ensure that any problems you have had documenting the HPI will become history.

Margaret Maley is a consultant with KarenZupko & Associates, a Chicago-based practice management company with more than 25 years of experience working with orthopaedic surgeons and their staffs.