Coding Corner, Administration/Practice Management
Coding Corner: Tips on how to document history in medical record
by from the AAP Division of Health Care Finance
"If it isn't documented, it hasn't been done" is an adage frequently heard in the health care setting. However,
many are unsure about who may document what in the medical record in order for it to count toward the history
level selection when reporting an evaluation and management service.
While the Centers for Medicare & Medicaid Services (CMS) has not provided a specific answer, much can be
inferred and there is a common understanding among coders, auditors and compliance officers.
Under history, four elements are required:
●
chief complaint (CC),
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review of systems (ROS),
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past family and social history (PFSH) and
history of present illness (HPI).
Q: What elements of the history can be documented by ancillary staff?
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A: Ancillary staff may record the ROS and/or PFSH. Alternatively, the patient may complete a form to provide
the ROS and/or PFSH. However, the reporting provider (e.g., physician) must supply a notation supplementing
or confirming the information recorded by others to document that he or she reviewed the information.
Q: What elements of the history must be documented by the reporting provider (e.g., physician)?
A: The reporting provider must gather and document the CC and HPI. While CMS documentation rules do not
explicitly state this, CMS infers this by excluding the elements from the ancillary provider guidance.
Q: Does the ROS or PFSH have to be re-recorded at every encounter?
A: ROS and/or PFSH obtained during an earlier encounter do not need to be re-recorded 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.
You may document the review and update by:
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describing any new ROS and/or PFSH information or noting there is no change in the information; and
noting the date and location of the earlier ROS and/or PFSH.
Q: What is the difference between the CC, ROS and HPI?
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A: Each element may be listed as separate elements of history, or the reporting provider may include them in
the description of the HPI. However, each element represents something different and is required to be
documented or noted:
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A CC is a concise statement that describes the symptom, problem, condition, diagnosis or reason for the
patient encounter. The CC usually is stated in the patient's own words.
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HPI is a chronological description of the development of the patient's present illness from the first sign
Copyright © 2016 American Academy of Pediatrics
Coding Corner, Administration/Practice Management
and/or symptom or from the previous encounter to the present.
●
ROS is an inventory of body systems obtained by asking a series of questions to identify signs and/or
symptoms that the patient may be experiencing or has experienced.
Becky Dolan, in the AAP Division of Health Care Finance, contributed to this article.
History element Who documents
Chief complaint Reporting provider
History of present Reporting provider
illness
Review
o fA n c i l l a r y s t a f f
systems
patient/family
Past family and A n c i l l a r y s t a f f
social history
patient/family
Special instructions
o r Reporting provider must note review or
add supplementation when documented
by ancillary staff or document and review
from a previous encounter.
o r Reporting provider must note review or
add supplementation when documented
by ancillary staff or document and review
from a previous encounter.
Resource
●
More information on history documentation
Email coding questions to [email protected]
Copyright © 2016 American Academy of Pediatrics