When It's Appropriate to Document a Comprehensive Patient History

by  Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
July 31st, 2014

Have you ever wondered when it is appropriate to document a comprehensive past medical, family and social history (PFSH) or if the necessity of doing so will be questioned during an audit?

Well, providers are concerned about how their documentation will hold up in an audit and since most haven’t been formerly trained in medical coding, their concerns over a potential audit are valid. 

Q: When is it appropriate to document a comprehensive past medical, family and social history?

A:  When the questions asked are being asked out of medical necessity and not because they are being asked to simply meet documentation requirements to reach the next highest EM service level. 

If the provider feels the questions being asked aid in determining proper diagnosis or medical treatment then they are medically necessary.

Q:  Who determines what is medically necessary?  

A:  The educated and trained medical provider who is responsible for diagnosing and treating the patient.  An auditor may question the need for a comprehensive PFSH, but as long as you can explain how the information relates to proper diagnosis or treatment (and/or the elimination of specific diagnoses or treatments) the documentation should be fine.

EM History Basics: 

Let’s review what determines how much history is required to reach the comprehensive PFSH, using the Office or Other Outpatient Services category (new and established patients).  

There are two new patient EM codes, within this category (99204-99205) and one established patient EM code (99215) that require a comprehensive history.

What determines a comprehensive history?  There are three areas of history to be documented and what is required in each to reach a comprehensive overall history:

The overall level of history is determined by the lowest score in any of the above-listed areas.  If all but one area meet the criteria then the whole history portion of the EM service is down coded to the level the one area qualifies for and cannot go higher.

Documentation Challenges:

Providers just want to diagnose and treat their patients accurately, quickly and fairly.  As such, they ask the right questions, take the proper history needed and don’t do more than they should or less than needed to achieve their goal of proper diagnosis and treatment.  

Documentation issues that interfere with proper EM coding include:  Electronic health record shortcuts like templates, copying and pasting segments of notes, and simply not enough time to edit and review patient documentation before signing it.

Electronic Medical Records (EMR):  

EMRs are detailed computer word processing programs that allow a provider to quickly and conveniently document the patient record and then have immediate access to it.  Some EMRs allow for voice recognition software to transcribe the note as it is dictated, others allow for transcribed dictation to be uploaded while other providers prefer to type the note while simultaneously caring for the patient and signing it upon conclusion of the EM service.

Templates create a note structure that makes it easy to meet documentation needs and a report that reads well.  However, when templates are not properly managed, they can be an avenue used for coding to a higher level of EM simply because they contain information that is gathered in one visit and then carried on to the next.

Copying and pasting can give a provider credit for a comprehensive history without having to actually need one for that particular visit.  This makes it possible to pass on documentation errors from previous notes, which can cause it’s own set of problems. 

Auditors are constantly on the lookout for notes that indicate copying and pasting is being done with regularity.  This is an area that when found can lead to the auditor downcoding the report, assessing refunds, fines and penalties and future additional audits.  All of which providers would like to avoid.  For more information on copying and pasting issues, please see the report titled, “The Dangers of Templates and Copying and Pasting in the EMR” located in Find-A-Code.

Suggestions:

Limit shortcuts in your documentation like copying and pasting that can lead to partial sentences, deleted information or over documentation and unwarranted up-coding.

  1. Use appropriate templates but beware, again of carrying forward any fixed information that doesn’t change from visit to visit and that requires dedicated editing.  This can result in upcoding as well.
  2. Verify that the history in each note is representative of the information that is actually needed to properly diagnose and treat the patient for that visit. 
  3. If you use a questionnaire for the ROS, be sure the provider reviews it with the patient and then signs and dates it to show that it was reviewed with the patient.  A scanned copy of the questionnaire should remain in the EMR program, linked to the EM service it pertains to.
  4. Take the time to read through each note (from beginning to end) before it is signed and dated.  This will aid in locating any errors before an auditor takes a look at it.

Again, a comprehensive PFSH is reported only when it is pertinent to the diagnosis and treatment of a patient, based on medical necessity.  Make sure each note containing a full PFSH clearly shows medical necessity before signing off on it.

When It's Appropriate to Document a Comprehensive Patient History. (2014, July 31). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/when-it-s-appropriate-to-document-a-comprehensive-patient-history-1493.html

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