Across the board, provider documentation reviews show a similar trend:  when it comes to deficiencies, most are identified in the History element of E/M documentation.  The History element includes the History of Present Illness (HPI), Review of Systems (ROS), and Past, Family and Social History (PFSH).  In order to support a high level of service (ED-99285), all three elements of History must be documented comprehensively. 

The HPI is designed to describe or modify the Chief Complaint.  A comprehensive HPI includes 4 or more elements of the following:  duration, timing, location, severity, modifying factors, context, associated signs/symptoms, and quality.  For example, if a patient presents with chest pain, the HPI might address when the pain started, where it is located (more specifically than simply “chest”), things that exacerbate or relieve the pain, and the kind of pain (sharp, dull, piercing).  Documentation of that nature would include duration, location, modifying factors, and quality, which would be sufficient to support a comprehensive history. 

The ROS is a subjective (from the patient’s perspective) evaluation of body/organ systems, designed to identify any potential additional areas of concerns that may need attention and/or treatment.  A comprehensive ROS includes 10 or more systems reviewed.  Earlier this year, Trailblazer (the Texas Medicare carrier) published new auditing guidelines for Evaluation and Management Services.  Among the changes, Trailblazer guidelines do not support the use of the phrase “all other systems are reviewed and negative” to obtain a comprehensive Review of Systems.  In an effort to comply with Trailblazer’s stance, many templates have been modified to have that statement removed.  In order to achieve a comprehensive level of ROS, there must 10 individually addressed systems reviewed.

The PFSH is obtained and documented to show any other conditions/illnesses that may have some impact on treatment.  The past history describes any current or chronic conditions or diseases of the patient.  It may also include past surgeries, allergies or current medications.  The social history addressed the social aspect of the patient’s life.  Tobacco and alcohol use are typically documented within the social history, as well as the patient’s marital status, living situation or occupation.  The family history is a brief overview of diseases that the patient’s family has encountered.  Most physicians limit the family history to immediate family, but it can include extended family.  Commonly addressed conditions include diabetes, heart disease and stroke.  A PFSH is considered comprehensive when at least two of the three elements are documented.

Documenting a comprehensive history is a requirement for high-level visits.  Making sure the history includes all these elements will ensure that a physician receives the appropriate reimbursement for the work they are doing.