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The Nuts and Bolts of E&M Coding,[object Object],Part 1 of 3 ,[object Object],Key Components of ,[object Object],History,[object Object],Presented by: Angie Nolan, CHA, CPC, CPC-I, PCS, RMA,[object Object],HIMS Educator – Banner Medical Group,[object Object]
E&M Codes Require Key Components,[object Object],The first Key component is the History which has 4 elements:,[object Object],CC or Chief Complaint,[object Object],HPI or History of Present Illness,[object Object],ROS or Review of Systems,[object Object],PFSH or Past Medical, Family, and Social History,[object Object]
What is the CC or Chief Complaint?	,[object Object],The CC is defined as a concise statement, usually in the patient’s own words, describing the symptom, problem, condition, diagnosis, or other factors for which the patient is seeking care from the physician or other non-physician practitioner; which is required at all history levels and must be clearly documented in the medical record for every visit. One exception to this is that subsequent hospital visits only require an interval problem focused history be documented in the medical record.,[object Object]
What is the HPI or History of Present Illness?,[object Object],The HPI is defined as a chronological description of the development of the patient’s present illness from the first sign or symptom to the present. ,[object Object],There are 2 levels of HPI ,[object Object],Brief which consists of 1 to 3 elements,[object Object],Extended which consists of 4 or more elements ,[object Object]
What are the elements of HPI?,[object Object],Location,[object Object],Duration,[object Object],Severity,[object Object],Quality,[object Object],Timing,[object Object],Modifying Factors,[object Object],Context,[object Object],Associated Signs and/or Symptoms,[object Object]
Let’s take a look at each element!,[object Object],Location: Where do the patient's symptoms occur?  In order to use location, it should be a place on the body that you could point to or touch and that the physician describes as the place where the patient's symptoms occur.  Head, shoulders, knees and toes.,[object Object]
Let’s take a look at each element!,[object Object],Duration: How long has the patient has these symptoms?  It could be short.  That is, the patient had them in the middle of last night, the symptoms have lasted for 24 hours, or it could be a longer time, such as longstanding, months, years.  Any description about the duration of the length of the patient's symptoms, illness or condition can be used as an element of duration.,[object Object]
Let’s take a look at each element!,[object Object],Severity:  That is, how bad are the patient's symptoms?  Are they getting better or worse, increasing or decreasing?  Sometimes a clinician might note the pain scale that the patient is having, such as 9 of 10.  The patient might be feeling well or okay.,[object Object]
Let’s take a look at each element!,[object Object],Quality:  What is the nature of the patient's symptoms? What is it like?  What characteristics describe the symptom?  Typically this will include colors, such as green, red, or yellowish.  It will include a description of the type of pain: burning, stabbing, dull, achy, etc.,[object Object]
Let’s take a look at each element!,[object Object],Timing:  That is, under what circumstances do the symptom occur?  Is it intermittent, continuous, constant, upon awakening, still, or after exercising?  Those are the kinds of words, which can be used to describe the timing of a symptom.,[object Object]
Let’s take a look at each element!,[object Object],Modifying factors:  The modifying factors are any treatments prescribed by a physician or tried by the patient without physician direction, which the patient has used to try and improve their symptoms.  It could be that the patient has been on antibiotics already for a week, or that the patient has tried elevating their leg without relief, or that they have tried over-the-counter medications.  Aspirin, rest, antibiotics, CABG.,[object Object]
Let’s take a look at each element!,[object Object],Context:  In order to answer this question, consider in what context the patient's symptoms occur.  Did they happen after a motor vehicle accident, after slipping on the ice, or in relation to another illness or surgery?  ,[object Object]
Let’s take a look at each element!,[object Object],Associated signs and symptoms: That is, other findings that the patient presents with, related or unrelated to today's chief complaint.  It could be that the patient came in and also complained of fever, weakness, confusion--any other symptom, which the patient describes.  We typically think of these elements as positive complaints, but many auditors will use a negative response in associated signs and symptoms.,[object Object]
FQA”s,[object Object],Can you use the same element twice?  The guidelines do not say yes or no about this. Some coding auditors report that in private communication CMS has told them that they can use the same element twice.  That is, they could use hip and leg, or hip and arm, as two elements if they were two different problems described in the HPI.  This is not verified in writing and it would be more conservative not to do that.  ,[object Object]
FQA’s,[object Object],Only the billing clinician may document the history of the present illness.  Unlike the chief complaint, review of systems, and past family medical and social history where a staff member might document part of the history as long as the physician has reviewed it, the history of the present illness must be documented by the billing provider.  ,[object Object]
FQA’s,[object Object],It is possible to use the status of three chronic diseases in place of the four elements of the history of the present illness.  This is especially helpful when treating patients with chronic problems such as diabetes, hypertension, and hyperlipidemia. In this case, specifically document the status of their problems at home in the history section.  Here is an example: “I am seeing this patient for follow-up for diabetes.  She reports her blood sugars at home to be in 150-200 range.  She is checking her sugars after meals.  Her current medication are X,Y and Z.”  Document the status of at least three of their chronic diseases in place of the four HPI elements.  Document one or the other. ,[object Object]
FAQ’s,[object Object],It is insufficient to simply list their chronic diseases in the history and document the status in the assessment in the plan.  The status of their chronic diseases must be documented in the HPI.  ,[object Object]
What is a ROS?,[object Object],The ROS is defined as 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.  ,[object Object],There are 3 levels of ROS,[object Object],Problem Pertinent which consists of 1 system (directly related to the presenting problem),[object Object],Extended which consists of 2 to 9 systems (directly related to the presenting problem and a limited number of additional systems),[object Object],Complete which consists of 10 or more systems (directly related to the presenting problem plus all additional systems),[object Object],Per CMS 1995 and 1997 Documentation Guidelines each of those systems with positives or (as it related to the chief complaint) pertinent negatives must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such notation, at least 10 systems must be individually documented.,[object Object]
What systems are recognized for a ROS?,[object Object],• Constitutional symptoms (e.g., fever, weight loss),[object Object],• Eyes,[object Object],• Ears, Nose, Mouth, Throat,[object Object],• Cardiovascular,[object Object],• Respiratory,[object Object],• Gastrointestinal,[object Object],• Genitourinary,[object Object],• Musculoskeletal,[object Object],• Integumentary (skin and/or breast),[object Object],• Neurological,[object Object],• Psychiatric,[object Object],• Endocrine,[object Object],• Hematologic/Lymphatic,[object Object],• Allergic/Immunologic,[object Object]
FAQ’s,[object Object],A ROS 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 or her own record or in an institutional setting or group practice where many physicians use a common record. ,[object Object],The review and update may be documented by:,[object Object],• describing any new ROS information or noting there has been no change in the information; and,[object Object],• noting the date and location of the earlier ROS.,[object Object],The ROS 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.,[object Object],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.,[object Object]
What is PFSH?,[object Object],Past (Personal) Medical History – a review of prior illnesses or injuries, operations, hospitalizations, medications, ect,[object Object],Family (Medical) History – a review of medical events in the patient’s family that are hereditary or place the patient at risk,[object Object],Social (Personal) History – review of habits such as smoking, drug use, living arrangements, occupation, ect,[object Object],There are 2 levels of PFSH,[object Object],Pertinent which consists of a review of the history area directly related to the presenting problem,[object Object],Complete which consists of a review of 2 or all 3 of the areas,[object Object]
FAQ’s,[object Object],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 or her own record or in an institutional setting or group practice where many physicians use a common record. ,[object Object],The review and update may be documented by:,[object Object],• describing any new PFSH information or noting there has been no change in the information; and,[object Object],• noting the date and location of the earlier PFSH.,[object Object],The 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.,[object Object],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.,[object Object]
Table of History Elements,[object Object]
Let’s Re-cap what we discussed today!,[object Object],4 Elements of History,[object Object],CC,[object Object],HPI,[object Object],ROS,[object Object],PFSH,[object Object]
Questions and Open Discussions,[object Object]

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The Nuts And Bolts Of E&M Coding

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