Don't Read This Article!

Have we got your attention? Good. Now join us for a scenic tour of HCFA's new documentation guidelines for history.

Anne Owen with Kent J. Moore

We've got good news and bad news. The good news is this: Now that HCFA has finally developed a standardized set of documentation guidelines for E/M services, you (and they) will have a precise yardstick against which to judge your coding and documentation practices. The bad news: Studying documentation guidelines is about as interesting as driving across Kansas on I-70. Sure, there are a few points of interest along the way ("Look, Ma, a hill!"), but most travelers adopt the strategy of cranking up the tape player and putting the pedal to the metal.

You might decide you want to use the same strategy to deal with these guidelines. After all, your time is precious and you already have to spend too much of it satisfying questionable and tiresome requirements. We understand. But consider this: There just might be a Kansas Highway Patrolman on the other side of that haystack up ahead. And he won't care that you found the speed limit annoying.

Perhaps we can help. We don't promise to thrill you, or even to entertain you, but we can point out the most important sections of the guidelines and take you through a few examples that might help you make some positive changes in your documentation practices. Studies have shown that for similar visits, family physicians use significantly lower codes than internists. We hate it when that happens. But maybe if we show you just what constitutes a detailed history in the eyes of HCFA, for example, we can jump-start your confidence in coding at the appropriate level.

Imagine for a minute that you're an American League baseball player. Pretend that three years ago, the leadership of the league decided that cricket, not baseball, would be the game you played. Imagine that they gave you new bats, balls and wickets and expected you to figure out the rules -- and win. For a long time, you felt overwhelmed, confused and uncertain; finally, you came up with your own cautious way of playing the game. Now, imagine that they're finally providing you with the rules.

Well, this is sort of like that. Three years ago, HCFA replaced the old customary and reasonable fee methodology with the new RBRVS-based system. Because of the enormity of the task of implementing an entirely new payment schedule for every physician in the country, HCFA resorted to a two-step method: The new codes were released Jan. 1, 1992, and the guidelines for documenting those codes were released at the tail end of 1994.

So now you have the new guidelines, or will have as soon as your Medicare carrier distributes them to you. Of course, as in the imagined story above, you have probably developed your own style of playing the game by now. But maybe you don't score many runs. Maybe there's a sweet spot on the bat that you don't even know about. And maybe, if you learned the difference between throwing and bowling, the umpire would stop calling "dead ball." In other words, these guidelines may offer some useful tips.

As you surely know, the level of E/M services you can legitimately claim is primarily dependent on the extent of history, examination and medical decision- making you employ. Because of the interdependency of these three key components, it is difficult to speak of any one in isolation. And yet, the topic is simply too huge to swallow in one gulp. So bear with us while we focus in on history in this article. And while we can't claim that documenting a history at a certain level necessarily implies a certain code, remember that it is the first step in getting there.

One of the most useful things these guidelines makes explicit is the extent to which you can delegate the task of gathering history to ancillary staff and to patients themselves. One guideline puts it this way:


The Review of Systems and the Past, Family and/or Social History may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.


What is the common procedure in your office for gathering or updating patient histories? How detailed are the questions your nurse asks patients before you walk into the exam room? How complete are the notes he or she makes in the chart? Do you have a thorough questionnaire that you ask patients to fill out?

Chances are, there is room for improvement in your system for obtaining patient information. One tool that you might want to consider is a registration and history record such as the one developed by Milcom, a medical records systems company, in conjunction with the Society of Teachers of Family Medicine. The forms, which are to be filled out by the patient, ask for all the essential information on present and past complaints and can be updated during subsequent visits. (For sample packets from Milcom, call 800-243-5546.)

The guidelines recognize that, once you've gathered the information, you do not have to repeat the entire Review of Systems (ROS) and Past, Family and/or Social History (PFSH) at each subsequent visit:


An ROS and/or a PFSH obtained during an earlier encounter does not need to be rerecorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:

Is this your common practice? When you do review earlier records, do you make a note of your review in the chart?

See chart below for an overview of the guidelines. As you will see, we've provided detailed descriptions of what elements should be considered as part of the History of Present Illness, Review of Systems and Past, Family and/or Social History.

As you may have noticed on the preceding chart, the thresholds dividing the different types of history are quite explicit. And each threshold is defined in terms of the number of items listed in the documentation. For instance, in terms of documentation, the only difference between a problem-focused history and an expanded problem-focused history is a problem-pertinent ROS: the documented review of one system. Other such thresholds (the difference between expanded problem-focused and detailed, and between that and comprehensive histories) involve documentation of additional items in two or three of the components of the history. Some study of the chart on the previous pages will help you get the distinctions clear in your mind: what makes the difference between one level of ROS or PFSH or HPI and another -- and when that difference makes a difference in the overall type of history.

In the HPI and PFSH, the difference between one level and the next may be no more than a word or two. For instance, the guidelines define a brief HPI as including documentation of one to three elements (location, quality, severity, etc.) of the present illness. For an extended HPI, four or more elements are required. Clearly, it does not take much to differentiate a brief HPI from an extended one. Here's an example of a brief HPI: "Patient has an intense [severity], throbbing [quality] pain in the neck [location]." Add duration to the mix, and you now have an extended HPI: "Patient has had an intense, throbbing pain in the neck since yesterday."

Similarly, the guidelines indicate another such small difference between a problem-pertinent ROS and an extended ROS. For a problem-pertinent ROS, you need only document a review of the system directly related to the problem or problems identified in the HPI. In comparison, the correct documentation of an extended ROS demonstrates inquiry about two to nine systems, one of which is the system directly related to the problem identified in the HPI. For example, let's say the problem identified in the HPI is a common cold, and you document an ROS of the ears, nose, mouth and throat. At this point, you have documented a problem-pertinent ROS. Note, however, that if you also document that you reviewed the respiratory system, you have documented an extended ROS.

A related point: To correctly document a complete ROS, you must show that you have reviewed at least 10 organ systems, one of which is the system directly related to the problem identified in the HPI. However, you do not have to individually document all the systems reviewed; you only have to document those with a positive or pertinent negative response if you document a review of the remaining systems with a notation like "all others negative." For example, if you see an elderly patient with severe chronic obstructive pulmonary disease, congestive heart failure and hypertension, you do not need to individually document all the systems reviewed. Instead, you could document the positive or pertinent negative responses for the relevant systems and then simply note, "all others negative" to cover the other systems reviewed.

According to Douglas E. Henley, MD, president-elect of the AAFP and a member of the AMA CPT Editorial Panel, a problem has already been identified in the documentation guidelines for documenting an extended HPI for patients with stable, multiple chronic problems. In such cases, it is possible that there would not be four or more elements to document, and yet the entire visit would entail sufficient complexity to warrant a higher code. Since the guidelines for HPI seem to assume acute illness, discussions are already under way with HCFA to make appropriate revisions to the guidelines to allow for the special case of patients with stable, multiple chronic problems. Look for news of the revision from your Medicare carrier and from Family Practice Management.

Enough of this fun. Let's take one patient -- an adult male (an established patient) with the chief complaint of cough with green sputum for seven days -- to illustrate the differences in documentation required for history at three different levels of service. To begin with, suppose the documentation of history for this visit read as follows:

CC: cough; patient has had a painful, progressive cough with green sputum for seven days. No fever or chills. Mild URI symptoms preceded the cough. There is no shortness of breath or chest pain. No history of bloody sputum.

He has had three episodes of bronchitis this year, the last one 2 months ago. Patient reports smoking one pack per day for the past 20 years.

The first sentence gives the chief complaint and four elements of the HPI. The rest of the paragraph documents the ROS for three systems (constitutional symptoms; ears, nose, mouth and throat; respiratory). The second paragraph documents elements from two areas of the PFSH. As you can see from the summary table (page 50), this constitutes a detailed history and would support a 99214 code.

What if the documentation had been less complete? If the second paragraph had been omitted entirely, leaving no PFSH, the type of history documented would have been reduced to expanded problem-focused, consonant with a 99213. (Note, however, that including either of the points made in this paragraph would be enough to raise the type of history to detailed.) Similarly, if less of the HPI had been included -- even a couple of words less -- the type of history would have decreased. If both paragraphs had been included, but the first sentence had read, "CC: cough; patient has had a cough with green sputum for seven days," the HPI would have dropped from extended (four elements) to brief (one to three elements), and the type of history would have dropped with it.

What if the history portion of the note had read simply, "CC: cough; patient has had a cough for seven days"? While not including enough detail to characterize the patient's situation clearly, this would still qualify as a problem-focused history consonant with a 99212. It includes the chief complaint and one element of the HPI.

That depends on you. You don't have to change the way you document E/M services if you don't want to. You certainly don't have to do anything different clinically. And remember that your carrier shouldn't be scrutinizing your documentation any more often just because the guidelines are in place. Unless you are subject to review, the nature of your documentation won't matter to HCFA. But maybe there are some fairly easy changes you can make in the way your office gathers information from patients. And maybe you can take a good hard look at your own documentation habits and see if there isn't room for improvement.

At the very least, you should be able to find some relief in the idea that finally there are objective, specific guidelines for documenting the various levels of service. If you ever are audited by your Medicare carrier, and you are able to demonstrate your adherence to those guidelines in your charts, you will be able to protect yourself from being downcoded.

Perhaps, after lingering for a while longer on these pages, and after studying the information in Family Practice Management's coming articles on the guidelines for documenting examination and medical decision-making, you will muster that extra edge of confidence in claiming the reimbursement you have rightfully earned, without fear of making yourself vulnerable to the whim of your carrier. And, from where we sit, that is no small thing.

Anne Owen is senior editor of Family Practice Management. Kent Moore is the AAFP's manager for reimbursement issues and a contributing editor to Family Practice Management.