History How-To: Point Your Provider in the Right Direction With These 5 History Tips

Why This Topic Matters

Accurate history documentation affects whether an evaluation and management service can be coded correctly and supported in the record. The guidance helps reduce downcoding risk and clarifies how providers can document history when the patient cannot supply it.

Article Sections

1. Documentation and history basics

   Introduces common documentation problems in patient history capture and explains why incomplete records can affect evaluation and management coding.

2. Tip 1: Distinguish history from exam

   Discusses the difference between history-taking and physical examination documentation and the importance of keeping those elements separate.

3. Tip 2: Record the information obtained

   Covers the need to document patient responses and other history details that are gathered during the encounter.

4. Tip 3: Avoid duplicate counting

   Explains the importance of not counting the same information more than once across history components.

5. Tip 4: Use patient history forms appropriately

   Describes how patient-completed forms can be incorporated into the record when reviewed by the physician.

6. Tip 5: Document when history cannot be obtained

   Addresses situations where a patient cannot provide a history and notes that the record should explain the circumstance in general terms.

7. CMS guidance reference

   Points to a CMS evaluation and management services guide cited as support for the documentation discussion.