e/m history of present illness

History of Present IllnessHistory of Present Illness

Jen Godreau, BA, CPC, CPEDCContent Director

Inhealthcare’s Supercoderjenniferg@supercoder.com

March 9, 2010

www.supercoder.com

Four parts of a History

Chief Complaint (CC)

History of Present Illness (HPI)

Past Medical Family Social History (PMFSH)

Review of Systems (ROS).

Example:99202: A level 2 new patient office visit requires

an expanded problem-focused history. An expanded problem focused history requires:

Type CPT Medicare

CC Required for sick Required for sick

HPI Brief 1-3 element/s

ROS Problem Pertinent 1 system

PFSH Not required

8 Areas That Help Determine HPI

8 Areas That Help Determine HPI

QualityRepresents the chief complaint

or signs or symptoms

TimingThe time of day the patient

experienced the signs and symptoms

8 Areas That Help Determine HPI

SeverityJust how serious is the

patient‘s condition?

DurationHow long have the

patient's signs and symptoms been present?

8 Areas That Help Determine HPI

Modifying FactorsWhat the patient did to

alleviate pain or exacerbate

Associated signs and symptoms

Are any other problems the patient has in addition to the chief complaint?

HPI Element Principles1997 EM Guidelines allow you to count the

status of chronic conditions • 1-2 chronic conditions counts as a brief HPI; 3

or more is an extended HPI

Physician must obtain and document the HPI• must indicate his actual review and interaction

Guidelines have never defined if staff are allowed to document the history of present illness

Ancillary staff does not have permission to collect the HPI

Ancillary staff can collect ROS and PFSH

E/M service code values include physician work for performing the HPI.

No double dipping. You get credit for any given HPI element only onceIn a note that indicates:

“dull, aching back pain,”

Dull +Aching 1 quality

Let’s try it!Est patient here today for sore throat (location) and

productive cough (associated signs and symptoms). Throat hurts worst at night (timing) and is a 7 (severity)

Solution?The physician documented four elements in

the note. Four elements counts as an extended HPI. For an established patient visit, an extended HPI supports a level greater than or equal to 99214. For a new patient visit code, extended HPI supports an E/M level greater than or equal to 99203 provided the visit meets all other required elements as well.

What Is ROS?Physician reviews systems directly related

to the problem or problems identified in the HPI portion of the E/M and a number of additional systems.

CPT defines ROS as: “an inventory of body systems obtained

through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced.”

ROS “helps define the problem, clarify the differential diagnosis, identify needed testing, or serves as baseline data on other systems that might be affected by any possible management options.”

Example: A patient reports to the FP complaining of a

headache. The FP inquires about how long the headache has lasted, and a few other questions to rule out migraines.

The FP discovers that the patient has not taken any medication for the headaches, he prescribes several over-the-counter options to deal with the condition, and tells the patient to come back in for another exam if the headaches worsen or increase in frequency. In this instance, you can only consider 1 system reviewed (neurological), since the FP

has apparently only inquired about the system directly related to the problem.

Count These SystemsCPT identifies the following ROS

elements

What Are the Different ROS Levels?

Problem-pertinent: When the physician reviews one system, you have a problem-pertinent ROS. This ROS level can support up to a level-two

new patient E/M (99202, an expanded problem-focused history; an

expanded problem-focused examination; and straightforward medical decision making) or a level-three established patient service (99213, … an expanded problem-focused history; an expanded problem-focused examination; medical decision-making of low complexity).

What Are the Different ROS Levels?

Extended: When the physician reviews two to nine systems, the encounter is an extended ROS.Extended ROS can support up to a level-three

new patient service (99203, … a detailed history; a detailed

examination; and medical decision-making of low complexity) or level-four established patient service (99214, … a detailed history; a detailed examination; medical decision-making of moderate complexity).

What Are the Different ROS Levels?Complete: For a complete ROS, most insurers accept

a review of 10 or more systems with all others documented. Per CPT, a complete ROS requires a review of all additional body systems. This would include 14 systems. The CMS Documentation Guidelines define a complete ROS as covering at least 10 organ systems. “A complete ROS inquires about the system(s) directly related

to the problem(s) identified in the HPI plus all additional body systems,” the E/M Documentation Guidelines state.

With a complete ROS, reporting a 99204, 99205 or is possible -- depending on other encounter specifics.

Example: An internist sees a patient with multiple chronic

conditions: COPD, CHF, hypertension, and diabetes. The physician asks questions about 10 of the systems, including constitutional, eyes, cardiovascular, respiratory, integumentary, neurological, and endocrine. He documents the positive and pertinent negative responses for 10 of the systems and writes: 10 of 14 systems obtained, remainder of systems are negative.

This documentation would count as a complete ROS.

Tips:You can use a form or template to record

ROS.Keep any form as part of the medical

recordWhen referring to old forms, include the

review date and location of the previously recorded information.

Include all 14 systems on form.

PMFSHDon’t need until you get to a detailed history

99214 – or on the new patient side a 99203. In the ED, you’d be talking about a 99284 (… a

detailed history; a detailed examination; and medical decision making of moderate complexity …)

PMFSHA complete PMFSH addresses 2 or 3 of the

PMFSH elements. Established patient visit requires 2 of 3Initial visits and consults requires 3 of 3

A complete PMFSH might support up to 99285. Including: 99204 99205 99215 99219/99220 99222/99223 99254 99255

Patient HistoryPast medical: look for information on the

patient’s allergies, current medications, past illnesses and surgeries, and any conditions that may be relevant to the presenting problem.

Example: A patient is taking insulin to treat her diabetes. The physician notes this, in case he decides to prescribe medication that may interact negatively with insulin.

Patient HistoryFamily history : a review of medical events

in the patient’s family, including diseases that may be hereditary or place the patient at risk. Also includes any inheritable condition or disease that is relevant to why the patient is seeking medical attention.

Example: A patient presents with rectal bleeding. The physician notes that the patient’s family has a history of colon cancer, this will affect treatment

Patient HistorySocial history is just as important as family

and past history.Items you should include:

• workplace• living conditions• marital status• age-appropriate review of past and

current activities 

Example:  A 50-year-old man presents to the ED with chest

pain.He has been experiencing shortness of breath and

upper extremity discomfort for the past four hours. The patient has a history of coronary artery disease (CAD) and hypertension (HTN). He is and has been a smoker for 20 years, and his father had cardiovascular disease and died of an acute myocardial infarction (MI) at age 53.In this instance, the physician addressed past (CAD,

HTN), family (father’s CAD), and social (smoker) histories. 3 PFSH supports a complete PFSH.

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Codes 99201 99202 99203 99204 99205

History Problem Focused

Expanded Problem Focused

Detailed Comprehensive

Comprehensive

Exam Problem Focused

Expanded Problem Focused

Detailed Comprehensive

Comprehensive

Decision Making

Straight forward

Straight forward

Low complex

Moderate complex

High complex

Time FF 10 20 30 45 60

Key # 3 of 3 3 of 3 3 of 3 3 of 3 3 of 3

Office Visits – Established Patient

Codes 99211 99212 99213 99214 99215

History Not Required

Problem Focused

Expanded Problem Focused

Detailed Comprehensive

Exam Not Required

Problem Focused

Expanded Problem Focused

Detailed Comprehensive

Decision Making

Not Required

Straight Forward

Low Complex

Mod Complex

High complex

Time FF 5 10 15 25 40

Key # 2 of 3 2 of 3 2 of 3 2 of 3 2 of 3

Levels of History

Level of History

Chief Complaint

(CC)

History of Present Illness (HPI)

Review of Systems (ROS)

Past, Family, Social History (PFSH)

CPT Medicare CPT Medicare CPT Medicare

Problem Focused

Required Brief 1-3 elements Not Required Not Required

Expanded Problem Focused

Required Brief 1-3 elements Problem- Pertinent

1 system Not Required

Detailed Required Extended 4 + elements OR 3+ chronic or inactive conditions

Extended 2-9 systems Pertinent 1 element

Comprehensive Required Extended 4 + elements OR 3+ chronic or inactive conditions

Complete 10 systems Complete 2 or 3 elements

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