Components of evaluation and management 2
Cracking the Code
Dr. Miller, who is in private practice in Yorba Linda, California, represents the American Academy of Dermatology on the AMA-CPT Advisory Committee.
By Alexander Miller, MD, June 1, 2018
After documenting a patient’s chief complaint and a history of the present illness (HPI) or illnesses, you move on to eliciting pertinent additional data within the history domain. Such data may include a review of systems and the patient’s past medical and social history, and family history. One should keep in mind that the data collected should be pertinent to the nature of the visit. Accruing and listing data simply because it is extractable but not pertinent to the problem being treated may in the end not count toward determining the final level of the visit. Similarly, regurgitating previously accrued patient history data for every patient encounter, particularly the review of systems and past medical history, if unchanged and not pertinent to the patient’s problem, may be judged to be irrelevant to the visit upon chart audit, and not counting toward the determination of complexity of the history.
Conclusion: collecting information not relevant to a patient’s problem(s) does not count toward determining the level of an evaluation and management (E/M) visit. Relevancy trumps volume.
The HPI may be brief and to the point, or extensive, depending upon the presenting problem. The review of systems and past history, including family history, should be gathered and reported when necessary for the patient’s evaluation.
The review of systems (ROS) includes the following:
- Constitutional symptoms (fever, weight loss, fatigue)
- Eyes
- Ears, nose, mouth, throat
- Cardiovascular
- Respiratory
- Gastrointestinal
- Genitourinary
- Musculoskeletal
- Integumentary (skin and/or breast)
- Neurological
- Psychiatric
- Endocrine
- Hematologic/lymphatic
- Allergic/immunologic
A history may include no review of systems, or a problem pertinent, extended, or complete ROS. Three levels of ROS are recognized:
- Problem pertinent
- Extended
- Complete
A problem pertinent ROS:
Reviews only the system relevant to the presenting problem.Example: Chief complaint of a localized pruritic skin eruption. ROS: no other areas of skin rash, pruritus, or other disorder of skin sensation.
An extended ROS:
Includes a review of the system related to the presenting problem as well as a review of additional systems for a total of 2-9 systems reviewed.Example: Patient with a diffuse, bilaterally symmetrical papulosquamous skin eruption. ROS reveals no pruritus or other disorder of skin sensation; no history of joint pain or swelling; no fever or fatigue, but a history of gradual weight gain over the years.
A complete ROS:
Requires a review of a minimum of 10 organ systems.
Example: Patient with a large cutaneous tumor and several tender satellite nodules. As metastatic disease is suspected, a complete ROS of 10 components is done.
The last history component is past medical history, family history, and social history (PFSH). These include:
Past medical history: prior diseases, surgeries, traumatic injuries, treatments, complications.
Family history: diseases, genetically transmitted conditions, other pertinent family data.
Social history: pertinent social, school, work, recreational activities; habits such as smoking, drug ingestion.
Two types of PFSH exist for purposes of history complexity determination: pertinent and complete.
A pertinent PFSH reviews data pertinent to the presenting problem. One or more components of the PFSH may be documented.
Example: New patient with a suspected squamous cell carcinoma. The patient is a surfer with a history of squamous cell carcinoma and of long-term sun exposure.
A complete PFSH requires a review of two or three of the three components of PFSH, depending upon the nature of the visit. For a new patient, one must document at least one ingredient from each of the three PFSH components. For an established patient, one must document at least one item from two of the PFSH components.
Example: New patient with a pigmented lesion suspicious for a melanoma. PFSH reveals a patient history of multiple previously biopsied atypical nevi and severe sunburns in youth when the patient was a lifeguard, and a maternal history of malignant melanoma.
The four levels of history and the components required to reach each level are illustrated in the chart below:
Example 1: A new patient with a diffuse morbilliform eruption is evaluated. You do a full review of all systems and record the data as: “ROS Negative by systems.” This satisfies the requirement for a complete ROS.
Answer: Incorrect. The chart record must individually document positive or negative system findings for systems relevant to the presenting problem. In this case, each organ system relevant to the problem should be documented for its negative or positive findings, such as: fever, chills, fatigue, malaise; throat pain; lymph node swelling; edema. Pertinent system negatives should also be listed. It is best to document each system as negative or positive, and list the characteristics of the positives. However, it is also permissible, after delineating the system positives/negatives specific to the patient’s problem, to simply list the organ systems with a negative ROS. (Note that this approach is only accepted by some payers.)
Example 2: Your new patient completes a form, entering review of systems and past medical history data. You then obtain the chief complaint and the pertinent history of the patient’s presenting problem(s). You review the form filled out by the patient and include that data in calculating the level of history for the patient’s visit.
Answer: Correct. A patient may enter the ROS and PFSH on a form, or ancillary staff may record this information. However, the physician/qualified health care professional must provide evidence of having reviewed this information. This may be done by dating and initialing.
Example 3: You are part of a dermatology group practice. You see a patient previously attended to by a colleague. You review previously recorded ROS and PFSH information and note in the record that it has not changed.
Answer: Almost Correct.One does not have to elicit previously gathered pertinent ROS and PFSH information with every visit. However, upon reviewing the data one should update any pertinent information and/or note that there was no change. Additionally, one should identify the date that the information was gathered, and its location in the patient record. Although this notation is appropriate for Medicare patients, individual insurers may have alternate requirements.
Example 4: During the course of extracting a patient history from a rambling patient you incorporate pertinent review of systems and PFSH data into the history narrative. Since the ROS and PFSH were not segregated into separate sections in the medical record you are reluctant to include them in the determination of the complexity of the patient visit.
Answer: Incorrect. There is no requirement for having separate sections for ROS and PFSH in the chart record. Although it may be easier to identify these components when they are segregated into their own compartments, the ROS and PFSH may be included in the HPI narrative. As long as they are documented in the patient record and pertinent to the visit they may be counted for determining the HPI level.
