The HPI should never be documented by ancillary staff (e.g., registered nurse, medical assistant, students). HPI might be documented by residents (e.g., residents, fellows, interns) or nonphysician providers (nurse practitioners and physician assistants) when utilizing the Teaching Physician Rules or Split-Shared Billing Rules, respectively (teaching Physician Rules and Split-Shared Billing Rules will be addressed in an upcoming issue).
Review of systems (ROS): This is a series of questions used to elicit information about additional signs, symptoms, or problems currently or previously experienced by the patient:
- Constitutional;
- Eyes; ears, nose, mouth, throat;
- Cardiovascular;
- Respiratory;
- Gastrointestinal;
- Genitourinary;
- Musculoskeletal;
- Integumentary (including skin and/or breast);
- Neurological;
- Psychiatric;
- Endocrine;
- Hematologic/lymphatic; and
- Allergic/immunologic.
The ROS may be classified as brief (a comment on one system), expanded (a comment on two to nine systems), or complete (a comment on more than 10 systems).
Documentation of a complete ROS (more than 10 systems) can occur in two ways:
- The physician can individually document each system. For example: “No fever/chills (constitutional) or blurred vision (eyes); no chest pain (cardiovascular); shortness of breath (respiratory); or belly pain (gastrointestinal); etc.”; or
- The physician can document the positive findings and pertinent negative findings related to the chief complaint, along with a comment that “all other systems are negative.” This latter statement is not accepted by all local Medicare contractors.
Information involving the ROS can be documented by anyone, including the patient. If documented by someone else (e.g., a medical student) other than residents under the Teaching Physician Rules or nonphysician providers under the Split-Shared Billing Rules, the physician should reference the documented ROS in his progress note. Re-documentation of the ROS is not necessary unless a revision is required.
Past, family, and social history (PFSH): Documentation of PFSH involves data obtained about the patient’s previous illness or medical conditions/therapies, family occurrences with illness, and relevant patient activities. The PFSH can be classified as pertinent (a comment on one history) or complete (a comment in each of the three histories). Documentation that exemplifies a complete PFSH is: “Patient currently on Prilosec 20 mg daily; family history of Barrett’s esophagus; no tobacco or alcohol use.”
As with ROS, the PFSH can be documented by anyone, including the patient. If documented by someone else (e.g., a medical student) other than residents under the Teaching Physician Rules or nonphysician providers under the Split-Shared Billing Rules, the physician should reference the documented PFSH in his progress note. Re-documentation of the PFSH is not necessary unless a revision is required. It is important to note that while documentation of the PFSH is required when billing higher level consultations (99254-99255) or initial inpatient care (99221-99223), it is not required when reporting subsequent hospital care services (99231-99233).
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Levels of History
There are four levels of history, determined by the number of elements documented in the progress note (see Table 1, p. 21). The physician must meet all the requirements in a specific level of history before assigning it.
If all of the required elements in a given history level are not documented, the level assigned is that of the least documented element. For example, physician documentation may include four HPI elements and a complete PFSH, yet only eight ROS. The physician can only receive credit for a detailed history. If the physician submitted a claim for 99222 (initial hospital care requiring a comprehensive history, a comprehensive exam, and moderate-complexity decision making), documentation would not support the reported service due to the underdocumented ROS. Deficiencies in the ROS and family history are the most common physician documentation errors involving the history component.