Practice Management

Document Patient History

A specific level of history is associated with each type of physician encounter, and must be documented accordingly (see Table 2, right). The most common visit categories provided by hospitalists that include documentation requirements for history are initial inpatient consultations, initial hospital care, subsequent hospital care, and initial observation care. Other visit categories, such as critical care and discharge day management, have neither associated levels of history nor documentation requirements for historical elements. TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is also on the faculty of SHM’s inpatient coding course.

CODE THESE CASES

Case 1 (deficient history): The hospitalist documents a problem-focused history (“no new events overnight”) after providing subsequent hospital care to a patient with uncontrolled diabetes mellitus, hypertension, status post hip repair. If documentation supports a detailed examination and medical decision making of high complexity, can the hospitalist appropriately report 99233 (subsequent hospital care requiring two of three key components: detailed history, detailed examination, high-complexity decision making)?

The Solution

Yes. Visit level selection is based upon three “key” components: history, exam, and medical decision-making. Some visit categories allow for visit level selection based on two of the three key components (e.g., subsequent hospital care) while others consider all three components (e.g., initial hospital care, inpatient consultations, and initial observation care). Although the “problem-focused” documentation involving the history component is insufficient for reporting 99233, visit-level selection for subsequent hospital care is based upon two key components. Since the hospitalist documented a detailed exam and high-complexity decision making, reporting 99233 is acceptable.

Case 2 (unable to obtain): Upon admission to the hospitalist service, an 82-year-old female presents with shortness of breath, dehydration, and confusion. The patient was transferred from her residence at a nursing facility without accompanying records. Limited information was obtained by the emergency medical technician, and the patient is an unreliable source. The available information is documented, but the level of history is only expanded problem-focused. Can the hospitalist receive additional credit for the history?

The Solution

Yes. The documentation guidelines specifically reference this situation. When the physician cannot elicit historical information from the patient, and no other source is available, the physician should document that he is “unable to obtain” the history and the circumstances surrounding this problem (e.g., patient confused, no caregiver present).

The hospitalist can receive “complete history” credit for his attempted efforts.—CP

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