Review of Histrory and Chief Complaint during E & M service

LEVEL OF EVALUATION AND MANAGEMENT SERVICE PERFORMED

The code sets used to bill for E/M services are organized into various categories and levels. In general, the more complex the visit, the higher the level of code the physician or NPP may bill within the appropriate category. In order to bill any code, the services furnished must meet the definition of the code. It is the physician’s or NPP’s responsibility to ensure that the codes selected reflect the services furnished. There are three key components when selecting the appropriate level of E/M service provided: history, examination, and medical decision making. Visits that consist predominately of counseling and/or coordination of care are an exception to this rule. For these visits, time is the key or controlling factor to qualify for a particular level of E/M services.


History

The elements required for each type of history are depicted in the table below. Further discussion of the activities comprising each of these elements is included below the table. To qualify for a given type of history, all four elements indicated in the row must be met. Note that as the type of history becomes more intensive, the elements required to perform that type of history also increase in intensity. For example, a problem focused history requires the documentation of the chief complaint (CC) and a brief history of present illness (HPI) while a detailed history requires the documentation of a CC, anextended HPI, plus an extended review of  systems (ROS), and pertinent past, family, and/or social history (PFSH).




TYPE OF HISTORY    CHIEF COMPLAINT   HISTORY OF PRESENT ILLNESS   REVIEW OF SYSTEMS    PAST, FAMILY,AND/OR SOCIAL HISTORY
                                                                                                                                                                           
Problem Focused        Required        Brief                 N/A                 N/A

Expanded Problem Focused     Required         Brief             Problem    Pertinent         N/A

Detailed        Required           Extended               Extended          Pertinent

Comprehensive      Required            Extended                 Complete        Complete


While documentation of the CC is required for all levels, the extent of information gathered for the remaining elements related to a patient’s history is dependent upon clinical judgment and the nature of the presenting problem.


Chief Complaint

A CC is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. The CC is usually stated in the patient’s own words. For example, patient complains of upset stomach, aching joints, and fatigue. The medical record should clearly reflect the CC.