Medical record - Documentation of History - How to

A. DOCUMENTATION OF HISTORY

The levels of E/M services are based on four types of history (Problem Focused, Expanded Problem Focused, Detailed, and Comprehensive). Each type of history includes some or all of the following elements:

Chief complaint (CC);

History of present illness (HPI);

Review of systems (ROS); and

Past, family and/or social history (PFSH).


The extent of history of present illness, review of systems, and past, family and/or social history that is obtained and documented is dependent upon clinical judgment and the nature of the presenting problem(s).

The chart below shows the progression of the elements required for each type of history. To qualify for a given type of history, all three elements in the table must be met. (A chief complaint is indicated at all levels.)

*DG: The CC, ROS and PFSH may be listed as separate elements of history, or they may be included in the description of the history of the present illness.

*DG: A ROS and/or a PFSH obtained during an earlier encounter does 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/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:

o describing any new ROS and/or PFSH information or noting there has been no change in the information; and

o noting the date and location of the earlier ROS and/or PFSH.

*DG: The ROS and/or PFSH 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.

*DG: If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history.

*Definitions and specific documentation guidelines for each of the elements of history are listed below.

GENERAL PRINCIPLES OF MEDICAL RECORD DOCUMENTATION

The principles of documentation listed below are applicable to all types of medical and surgical services in all settings. For Evaluation and Management (E/M) services, the nature and amount of physician work and documentation varies by type of service, place of service and the patient's status. The general principles listed below may be modified to account for these variable circumstances in providing E/M services.

1. The medical record should be complete and legible.

2. The documentation of each patient encounter should include:

reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results;

assessment, clinical impression, or diagnosis;

plan for care; and

date and legible identity of the observer.


3. If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred.

4. Past and present diagnoses should be accessible to the treating and/or consulting physician.

5. Appropriate health risk factors should be identified.

6. The patient's progress, response to and changes in treatment, and revision of diagnosis should be documented.

7. The CPT and ICD-9-CM codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record.

Documentation Requirements for Billing Observation or Inpatient Care Services

(Including Admission and Discharge Services)

The physician shall satisfy the E/M documentation guidelines for furnishing observation care or inpatient hospital care. In addition to meeting the documentation requirements for history, examination, and medical decision making, documentation in the medical record shall include:

• Documentation stating the stay for observation care or inpatient hospital care involves 8 hours, but less than 24 hours;

• Documentation identifying the billing physician was present and personally performed the services; and

• Documentation identifying the order for observation services, progress notes, and discharge notes were written by the billing physician.

In the rare circumstance when a patient receives observation services for more than 2 calendar dates, the physician shall bill observation services furnished on day(s) other than the initial or discharge date using subsequent observation care codes. The physician may not use the subsequent hospital care codes since the patient is not an inpatient of the hospital.



D. Admission to Inpatient Status Following Observation Care

If the same physician who ordered hospital outpatient observation services also admits the patient to inpatient status before the end of the date on which the patient began receiving hospital outpatient observation services, pay only an initial hospital visit for the evaluation and management services provided on that date. Medicare payment for the initial hospital visit includes all services provided to the patient on the date of admission by that physician, regardless of the site of service. The physician may not bill an initial or subsequent observation care code for services on the date that he or she admits the patient to inpatient status. If the patient is admitted to inpatient status from hospital outpatient observation care subsequent to the date of initiation of observation services, the physician must bill an initial hospital visit for the services provided on that date. The physician may not bill the hospital observation discharge management code (code 99217) or an outpatient/office visit for the care provided while the patient received hospital outpatient observation services on the date of admission to inpatient status.

Confidentiality of Member Medical Records

Tufts Health Plan requires that providers comply with all applicable state and federal laws relating to the confidentiality of member medical records, including but not limited to the privacy regulations of the Health Insurance Portability and Accountability Act (HIPAA).

To meet Tufts Health Plan confidentiality requirements, providers must do the following:

? Maintain medical records in a space staffed by office personnel

? Maintain medical records in a locked office when staff is not present

? Prohibit unauthorized review and/or removal of medical records

? Maintain and adhere to policies and procedures regarding patient confidentiality.



Tufts Health Plan also requires that providers, upon request, provide member medical information and medical records for the following purposes:

? Administering its health benefit plans, such as claims payment, coordination of benefits, subrogation, enrollment eligibility verification, reinsurance, and audit activities

? Managing care, including but not limited to utilization management and quality improvement activities

? Carrying out member satisfaction procedures described in member benefit booklets

? Participating in bona fide medical research and in reporting on quality and utilization indicators, such as Healthcare Effectiveness Data and Information Set (HEDIS®)

? Complying with all applicable federal and state laws.




Providers are responsible for obtaining any member consents or releases that are necessary beyond those that Tufts Health Plan has already acquired through the enrollment process or the member benefit booklets. Tufts Health Plan maintains and uses member medical information in accordance with Tufts Health Plan’s confidentiality policies and procedures.

DOCUMENTATION OF THE COMPLEXITY OF MEDICAL DECISION MAKING

The levels of E/M services recognize four types of medical decision making (straightforward, low complexity, moderate complexity, and high complexity). Medical decision making refers to the complexity of establishing a diagnosis and/or selecting a management option as measured by:

the number of possible diagnoses and/or the number of management options that must be considered;

the amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed, and analyzed; and

the risk of significant complications, morbidity, and/or mortality, as well as comorbidities associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the possible management options.

The chart below shows the progression of the elements required for each level of medical decision making. To qualify for a given type of decision making, two of the three elements in the table must be either met or exceeded.

How to Document examination in Medical record

DOCUMENTATION OF EXAMINATION

The levels of E/M services are based on four types of examination that are defined as follows:

Problem Focused -- a limited examination of the affected body area or organ system.

Expanded Problem Focused -- a limited examination of the affected body area or organ system and other symptomatic or related organ system(s).

Detailed -- an extended examination of the affected body area(s) and other symptomatic or related organ system(s).

Comprehensive -- a general multi-system examination or complete examination of a single organ system.



For purposes of examination, the following body areas are recognized:

Head, including the face

Neck

Chest, including breasts and axillae

Abdomen

Genitalia, groin, buttocks

Back, including spine

Each extremity



For purposes of examination, the following organ systems are recognized:

Constitutional (e.g., vital signs, general appearance)

Eyes

Ears, nose, mouth, and throat

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Musculoskeletal

Skin

Neurologic

Psychiatric

Hematologic/lymphatic/immunologic



The extent of examinations performed and documented is dependent upon clinical judgment and the nature of the presenting problem(s). They range from limited examinations of single body areas to general multi-system or complete single organ system examinations.

DG: Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. A notation of "abnormal” without elaboration is insufficient.

DG: Abnormal or unexpected findings of the examination of the unaffected or asymptomatic body area(s) or organ system(s) should be described.

DG: A brief statement or notation indicating "negative" or "normal" is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s).

DG: The medical record for a general multi-system examination should include findings about 8 or more of the 12 organ systems.

Documenting Past, Family, Social history in Medical record

PAST, FAMILY, AND/OR SOCIAL HISTORY (PFSH) 

The PFSH consists of a review of three areas:

past history (the patient's past experiences with illnesses, operations, injuries and treatments);

family history (a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk); and social history (an age appropriate review of past and current activities).


For the categories of subsequent hospital care, follow-up inpatient consultations and subsequent nursing facility care, CPT requires only an "interval" history. It is not necessary to record information about the PFSH.

A pertinent PFSH is a review of the history area(s) directly related to the problem(s) identified in the HPI.

DG: At least one specific item from any of the three history areas must be documented for a pertinent PFSH.

A complete PFSH is of a review of two or all three of the PFSH history areas, depending on the category of the E/M service. A review of all three history areas is required for services that by their nature include a comprehensive assessment or reassessment of the patient. A review of two of the three history areas is sufficient for other services.

DG: At least one specific item from two of the three history areas must be documented for a complete PFSH for the following categories of E/M services:

office or other outpatient services, established patient; emergency department;

subsequent nursing facility care; domiciliary care, established patient; and home care, established patient.


DG: At least one specific item from each of the three history areas must be documented for a complete PFSH for the following categories of E/M services: office or other outpatient services, new patient; hospital observation services; hospital inpatient services, initial care; consultations; comprehensive nursing facility assessments; domiciliary care, new patient; and homecare, new patient.

Medical record document - Review of system

REVIEW OF SYSTEMS (ROS)

A ROS is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced.


For purposes of ROS, the following systems are recognized:

Constitutional symptoms (e.g., fever, weight loss)

Eyes

Ears, Nose, Mouth, Throat

Cardiovascular

Respiratory

Gastrointestinal

Genitourinary

Musculoskeletal

Integumentary (skin and/or breast)

Neurological

Psychiatric

Endocrine

Hematologic/Lymphatic

Allergic/Immunologic

A problem pertinent ROS inquires about the system directly related to the problem(s) identified in the HPI.

DG: The patient's positive responses and pertinent negatives for the system related to the problem should be documented.

An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems.

DG: The patient's positive responses and pertinent negatives for two to nine systems should be documented.


A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.

DG: At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented.

Medical record - History of Present illness and chief complaint

CHIEF COMPLAINT (CC)

The CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter.

DG: The medical record should clearly reflect the chief complaint.


HISTORY OF PRESENT ILLNESS (HPI)

The HPI is a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present. It includes the following elements:

location;

quality;

severity;

duration;

timing;

context;

modifying factors; and

associated signs and symptoms.


Brief and extended HPIs are distinguished by the amount of detail needed to accurately characterize the clinical problem(s).

A brief HPI consists of one to three elements of the HPI.

DG: The medical record should describe one to three elements of the present illness (HPI).

An extended HPI consists of four or more elements of the HPI.

DG: The medical record should describe four or more elements of the present illness (HPI) or associated comorbidities.

How to Document E & M services

DOCUMENTATION OF E/M SERVICES

This publication provides definitions and documentation guidelines for the three key components of E/M services and for visits which consist predominately of counseling or coordination of care. The three key components--history, examination, and medical
decision making--appear in the descriptors for office and other outpatient services, hospital observation services, hospital inpatient services, consultations, emergency department services, nursing facility services, domiciliary care services, and home services. While some of the text of CPT has been repeated in this publication, the reader should refer to CPT for the complete descriptors for E/M services and instructions for selecting a level of service. Documentation guidelines are identified by the symbol  • DG.

The descriptors for the levels of E/M services recognize seven components which are used in defining the levels of E/M services. These components are:


history;

examination;

medical decision making;

counseling;

coordination of care;

nature of presenting problem; and

time.


The first three of these components (i.e., history, examination and medical decision making) are the key components in selecting the level of E/M services. An exception to this rule is the case of visits which consist predominantly of counseling or coordination
of care; for these services time is the key or controlling factor to qualify for a particular level of E/M service.

For certain groups of patients, the recorded information may vary slightly from that described here. Specifically, the medical records of infants, children, adolescents and pregnant women may have additional or modified information recorded in each history
and examination area.


As an example, newborn records may include under history of the present illness (HPI) the details of mother’s pregnancy and the infant's status at birth; social history will focus on family structure; family history will focus on congenital anomalies and hereditary
disorders in the family. In addition, information on growth and development and/or nutrition will be recorded. Although not specifically defined in these documentation guidelines, these patient group variations on history and examination are appropriate.

What is Medical record and why its important

WHAT IS DOCUMENTATION AND WHY IS IT IMPORTANT**

Medical record documentation is required to record pertinent facts, findings, and observations about an individual's health history including past and present illnesses, examinations, tests, treatments, and outcomes. The medical record chronologically documents the care of the patient and is an important element contributing to high quality care. The medical record facilitates:

the ability of the physician and other healthcare professionals to evaluate and plan the patient’s immediate treatment, and to monitor his/her healthcare over time;

communication and continuity of care among physicians and other healthcare professionals involved in the patient's care;

accurate and timely claims review and payment;

appropriate utilization review and quality of care evaluations; and collection of data that may be useful for research and education.

An appropriately documented medical record can reduce many of the "hassles" associated with claims processing and may serve as a legal document to verify the care provided, if necessary.


WHAT DO PAYERS WANT AND WHY**

Because payers have a contractual obligation to enrollees, they may require reasonable documentation that services are consistent with the insurance coverage provided. They may request information to validate:

the site of service;

the medical necessity and appropriateness of the diagnostic and/or therapeutic services provided; and/or

 that services provided have been accurately reported.

GENERAL PRINCIPLES OF EVALUATION AND MANAGEMENT DOCUMENTATION

“If it isn’t documented, it hasn’t been done” is an adage that is frequently heard in the health care setting.

Clear and concise medical record documentation is critical to providing patients with quality care and is required in order for providers to receive accurate and timely payment for furnished services. Medical records chronologically report the care a patient received and are used to record pertinent facts, findings, and observations about the patient’s health history. Medical record documentation assists physicians and other health care professionals in evaluating and planning the patient’s immediate treatment and monitoring the patient’s health care over time.


Health care payers may require reasonable documentation to ensure that a service is consistent with the patient’s insurance coverage and to validate:

? The site of service;

? The medical necessity and appropriateness of the diagnostic and/or therapeutic services provided; and/or

? That services furnished have been accurately reported. There are general principles of medical record documentation that are applicable to all types of medical and surgical services in all settings. While E/M services vary in several ways, such as the nature and amount of physician work required, the following general  Evaluation and Management Services Guide principles help ensure that medical record documentation for all E/M services is appropriate:

? The medical record should be complete and legible;

? The documentation of each patient encounter should include:

• Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results;

• Assessment, clinical impression, or diagnosis;

• Medical plan of care; and

• Date and legible identity of the observer.

? If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred;

? Past and present diagnoses should be accessible to the treating and/or consulting physician;

? Appropriate health risk factors should be identified;

? The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented; and

? The diagnosis and treatment codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record. In order to maintain an accurate medical record, services should be documented during the encounter or as soon as practicable after the encounter.

Document requirement for CPT CODES 99204 and 99205

Prepayment of evaluation and management codes 99204 and 99205

Data analysis was conducted recently due to the high comprehensive error rate testing (CERT) error rate for evaluation and management service pertaining to Current Procedural Terminology (CPT®) codes 99204 (Office/outpatient visit new) and 99205 (Office/outpatient visit new). CERT reviews indicated the errors were based on insufficient documentation and services coded incorrectly.

Documentation requirements

The American Medical Association (AMA) CPT® manual defines code 99204 as follows:
Office or other outpatient visit for the evaluation and management (E/M) of a new patient, which requires these three key components:
• A comprehensive history
• A comprehensive examination
• Medical decision making of moderate complexity.

Usually the presenting problem(s) are of moderate to high severity. Typically, 45 minutes are spent face-to-face with the patient and/or family.
The American Medical Association (AMA) CPT® manual defines code 99205 as follows:

Office or other outpatient visit for the evaluation and management (E/M) of a new patient, which requires three key components:

• A comprehensive history
• A comprehensive examination
• Medical decision making of high complexity.

Usually the presenting problem(s) are of moderate to high severity. Typically, 60 minutes are spent face-to-face with the patient and/or family.
Furthermore, claims submitted with E/M code 99204 and 99205 must be supported by documentation indicating the medical necessity for this level of service.

Prepayment of evaluation and management code 99215

First Coast Service Options Inc. (First Coast) recently conducted data analysis due to the high comprehensive error rate testing (CERT) error rate for evaluation and management service pertaining Current Procedural Terminology (CPT®) code 99215 (Office/outpatient visit established). CERT reviews indicated the errors were based on insufficient documentation, medically unnecessary services and services incorrectly coded.

Documentation requirements

The American Medical Association (AMA) CPT® manual defines code 99215 as follows:
Office or other outpatient visit for the evaluation and management (E/M) of an established patient, which requires at least two of these three key components:

• A comprehensive history
• A comprehensive examination
• Medical decision making of high complexity.

Usually the presenting problem(s) are of moderate to high severity. Typically, 40 minutes are spent face-to-face with the patient and/or family.

Furthermore, claims submitted with E/M code 99215 must be supported by documentation indicating the medical necessity for this level of service.

Reviewing of Medical record and decision Making Q & A

Q. Can I refer to someone else’s dictated note and get credit for those parts of the history I reviewed?
A. Yes - review of “old records” is part of the medical decision-making process.


Q. If I review my own previous notes and summarize my findings, would I get credit for “review and summation of old records”?
A. No, credit would not be given for summarizing one’s own previous records.


Q. If I document allergies, do I get credit for an element of past medical history, or is this counted as part of the review of systems (Allergic/Immunologic) (or both)?
A. The single element of allergies would only be counted once (for either past medical history or review of systems).



Q. Can I use elements of History of Present Illness (HPI) as elements of Review of Systems (ROS) and have them both count, or is it one or the other? For example if the patient has chest pain which is “associated with shortness of breath” in the HPI, does this also count as an element of respiratory ROS?
A. The same element would only be counted once. In the example given, there are two different elements indicated (shortness of breath and chest pain), so this would count for both HPI and ROS, respectively.


Q. Do you use the numeric conversion for the 1995 E/M guidelines (i.e., problem focused exam: one system and/or body area, expanded problem focused exam: 2-4 organ systems and/or body areas, detailed exam: 5-7 body areas and/or organ systems, comprehensive: 8 organ systems)?
A. The 1995 guidelines do not specify exact numbers -- problem focused implies one system/area, and only comprehensive has a numeric indication (8).





Q. What is the definition of “self-limited” or “minor” problem vs. “new stable problem?”
A. A new, stable problem is a new problem, which is not worsening. A self-limited or minor problem is of less severity and would be expected to run its course uneventfully.


Q. When referring to my own previously dictated notes for the Review of Systems (ROS) and Past, Family and Social History (PFSH), do I have to note the date AND location of the previous note, e.g., “Previous PFSH and complete ROS was reviewed with the patient and is unchanged. For details, please refer to my dictated note IN THIS CHART dated 5/6/09.”
A. Yes -- when referring to previous notes, specific information must be given regarding when and where.


Q. When calculating the medical decision-making, are problems defined as “old” or “new” relative to the patient or to the physician?
A. Regarding the medical decision-making component, the designations of “old” and “new” are relative to the physician.

Prescription Drug Management in Medical record

Q. During an evaluation and management visit, what constitutes “prescription drug management?”

A. “Prescription drug management” is based on documented evidence that the provider has evaluated medications as part of a service, in relation to the patient. This may be a prescription being written or discontinued, or a decision to maintain a current medication/dosage.
Note: Simply listing current medications is not considered “prescription drug management.”


Q. What is required to get credit for prescription drug management? Do I have to stop, start or change a medication dosage, or can I get credit for making the decision to continue a specific medication?
A. Credit is given as long as the documentation clearly indicates that decision-making took place in regard to the medication(s).

Q. Is prescription drug management enough to establish a moderate level of risk for medical decision-making?
A. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. The highest level of risk in any one category determines the overall risk.


Q. Is prescription drug management enough to establish a moderate level of risk for medical decision-making?
A. The assessment of risk of selecting diagnostic procedures and management options is based on the risk during and immediately following any procedures or treatment. The highest level of risk in any one category determines the overall risk.



Q. In medical-decision making, how does one determine further work-up under “number of diagnoses”?
A. A key element of the medical-decision making category includes management decisions made by the physician to determine a diagnosis and treatment. Evidence of further work-up within documentation would include: indicating a problem is worsening/probable and/or listing possible management options, advice sought, referrals or consultations, and the initiation of or change in treatment.


Q. What does a “self-limited or minor problem” mean? Can you please give some examples?
A. A self-limited or minor problem is one in which the resolution is expected to be fairly rapid, with minimal medical intervention.  Examples would be a cold or an insect bite.

E & M Visit Q & A - Do physician required to document the date in Medical record - Observation care ?

Q. In regard to observation care, must a physician document date and time in the medical record, or is the nursing documentation sufficient to verify date and time?

A. Regarding documentation requirements on behalf of a physician who is billing for observation care, the Internet-only manual states:

For a physician to bill the initial observation care codes, there must be a medical observation record for the patient which contains dated and timed physician’s orders regarding the observation services the patient is to receive, nursing notes, and progress notes prepared by the physician while the patient received observation services. This record must be in addition to any record prepared as a result of an emergency department or outpatient clinic encounter.



Q. If my office uses an E/M questionnaire for the Past, Family and Social History (PFSH) and Review of Systems (ROS), is it mandatory that the physician sign and date the form?

A. It is mandatory that the physician’s documentation clearly indicates that the forms have been reviewed by him/her, and that any follow-up on positive and pertinent negative responses is documented.


Q. Can I document the most clinically relevant systems and then say “all other systems reviewed are negative” in order to qualify for a complete (10 system) ROS?
A. This would be allowed if all other systems were, indeed, reviewed and are negative, and if a complete ROS is medically necessary.


Q. If the patient’s medical record indicates that the PFSH is “non-contributing” with regard to the patient’s condition, does this documentation support that the PFSH was reviewed?

A. If the record indicates that the patient’s past, family, and social history (PFSH) is “non-contributing,” it may be inferred that the practitioner did not ask the patient about his or her PFSH. However, if the practitioner has reviewed the patient’s PFSH, it should be documented in the medical record.

Q. When referring to my own previously dictated notes for the Review of Systems (ROS) and Past, Family and Social History (PFSH), do I have to note the date AND location of the previous note, e.g., “Previous PFSH and complete ROS was reviewed with the patient and is unchanged. For details, please refer to my dictated note IN THIS CHART dated 5/6/09.”

A. Yes -- when referring to previous notes, specific information must be given regarding when and where.