1. Documenting Patient Care

2. Objectives
Identify the components and rules for choosing the levels of Evaluation and Management (E/M) services
Learn how chronic conditions can count as part of History
Discover keys to documenting creditworthy examinations
Practice creating compliant notes
Apply principles to specific practice samples

3. Components of E/M Services
History
Physical Exam
Medical Decision Making
Counseling
Coordination of Care
Time
Nature of Presenting Problem

4. Elements of History CC HPI ROS PFSH Chief complaint
Usually in the patient’s words, this establishes “medical necessity”
HPI
History of Present Illness
Chronological description of the development of the patient’s present illness from first sign and/or symptom
ROS
Review of systems
PFSH
Past Medical, Family, and Social History

5. Elements of HPI Location Quality Severity Duration Timing Context
Modifying Factors
Associated Signs & Symptoms

6. Elements of HPI (cont.) Location Duration Severity
Where the problem is occurring
Often the same as the chief complaint
Specific descriptors (e.g., rt leg, chest, frontal)
– Words like “systemic” are questionable
Duration
How long the patient has had the problem
Includes specific and non-specific descriptors (e.g., 3 hours, couple of days, several months, since June)
– Don’t use very generic terms like “a long time”
Severity
How bad is the condition or disease
Use words like severe, uncontrolled, improving
If you choose to use specific rating or pain on a scale of 1 – 10, get a point of reference from the patient

7. Elements of HPI (cont.) Quality Context Timing
Descriptive terms that further define the condition
e.g., Raised, itchy, productive, supporative
Context
Circumstances under which the condition occurred
e.g., At work, while walking, when lying down
Timing
Time of the day or other associated timing
e.g., After meals, every morning

8. Elements of HPI (cont.) Modifying Factors
Things the patient has done to improve the condition
e.g., Took aspirin, previous prescription, surgery or hospitalizations, put feet up
Doesn’t matter if effort was successful or not
Associated Signs and Symptoms
Additional problems that may be related to the chief complaint

9. Alternative HPI Can be current status of three chronic illness
e.g., Hypertension, CHF, COPD, Diabetes
Must be reason for visit
1 – 2 illness is brief HPI
3 is extended HPI

10. Review of Systems Current status of various body systems
14 systems can be reviewed
Listed in CPT “Evaluation and Management Services Guidelines” page 8
Review may be positive or negative
e.g., Patient has frequent headaches
e.g., Patient denies vision change
Similar to “Associated Signs and Symptoms
ROS can be gleaned from anywhere in your documentation

11. Elements of ROS Constitutional Eyes Ears, Nose, Mouth, Throat
Weight loss, general health
Eyes
Changes of vision, discharge, tearing
Ears, Nose, Mouth, Throat
Hearing, pain, dryness, hoarseness, drainage
Cardiovascular
Chest pain, irregular heartbeats, edema
Respiratory
Shortness of breath, wheezing, cough, orthopnea

12. Elements of ROS (cont) Gastrointestinal Genitourinary Musculoskeletal
Constipation or diarrhea, heartburn, pain, vomiting
Genitourinary
Incontinence, burning, itching, genital rashes, initial onset of menses
Musculoskeletal
Pain, stiffness, strength
Integumentary
Rashes, sores, changes in hair or nails
Neurological
Dizziness, loss of sensation, weakness, seizures, pain

13. Elements of ROS (cont.) Psychiatric Endocrine Hematologic/Lymphatic
Mental status changes, nervousness, confusion, fear
Endocrine
Change in blood sugar levels, dehydration
Hematologic/Lymphatic
Swelling, fatigue, bleeding, bruising, varicose veins
Allergic/Immunologic
Swelling, rashes, frequency of infections

14. Level of ROS 1 system reviewed 2 – 9 systems reviewed
Problem Pertinent ROS
2 – 9 systems reviewed
Extended ROS
10 or more systems reviewed
Complete ROS

15. PFSH Past Medical History Family History Social History
Previous diseases, hospitalizations, surgeries, medications, allergies
Family History
Significant medical history of family members including cause of death and hereditary illnesses
Social History
Marital status, living arrangements, employment, smoking, drinking, drug use

16. Level of PFSH One element only Two or three elements
Pertinent PFSH
Two or three elements
Complete PFSH
Two elements for codes for established patients or subsequent visits
All three elements required for new patients, initial visits, consults, etc.

17. History
When a physician selects a level of care and then discovers it to be overcoded, it is usually a deficiency in the documentation in the History section. That is because in selecting the level of History, all three of the components, HPI, ROS and PFSH, must be met at the level indicated to select a particular level of history.

18. Selecting the level of History 3/3
99204
99205
99215
99201
99212
99202
99213
99203
99214
Problem Focused
Expanded Problem Focused
Detailed
Comprehensive
HPI
Brief
1-3
Extended
4 or more
ROS
None
Pertinent to problem
1 system
2-9
Complete
10 or more
PFSH
Pertinent
1 area
2 or 3 areas

19. Without a Review of Systems (ROS) the highest possible code for a
new patient is: 99201
established patient is 99212
Without a Past, Family, and Social History (PFSH) the highest possible code for a
new patient is: 99202
established patient is 99213

20. Document at least 2 systems in your ROS making it an extended ROS.
A good rule of thumb for the History of Present Illness (HPI) is to document at least 4 elements making it an extended HPI.
Document at least 2 systems in your ROS making it an extended ROS.
Document at least 1 item in past, family or social history to get a pertinent PFSH.

21. HISTORY
The level of history you document serves as a foundation for your final selection of level of care.

22. Example: History Dictation
Patient in today with some pain. Does not feel good. Patient is accompanied by sister who states that she had to ask for the afternoon off to bring the patient in due to the pain.
NO location, duration, quality, severity, timing, context, modifying factors, associated signs and symptoms, ROS, PFSH = NO Hx

23. Example: History Dictated:
Location
Dictated:
The patient in c/o abdominal pain since yesterday.
2 elements of History of Present Illness (HPI) noted = Brief HPI
No Review of Systems.
No Past, Family, Social History.
History requires that all three be met in order to select a level of History.
This is a PROBLEM FOCUSED History.
Duration

24. Example: History Dictation
Location
Dictation
The patient in c/o abdominal pain since yesterday. Patient states it is a burning sensation and places pain level at a six out of ten.
4 Elements of HPI. No ROS. No PFSH.
Still a PROBLEM FOCUSED History.
You can’t get any higher without a review of systems (ROS).
duration
quality
severity

25. Example: History Dictation
location
Dictation
The patient in c/o abdominal pain since yesterday. Patient states it is a burning sensation and places pain level at a six out of ten. ROS negative for GI and otherwise significant for palpitations 2 years ago. No one else in the family has any symptoms.
The additional 2 items of ROS and 1 PFSH make this a DETAILED History.
duration
quality
severity

26. Elements of HPI
Extended or Brief?
HPI: Mary Smith was seen in my clinic today on referral by Dr.
Jones. She is a 46-year-old woman who presents with a right
breast lump which she noticed on breast self exam 2 weeks
ago. She performs breast exam monthly and has not noticed the
lump previously. She states that the lump is quite firm and
somewhat tender to touch. She denies weight loss or nipple
discharge.
6 Elements of HPI:
Location, context, duration, quality,
severity, associated signs and
symptoms

27. ROS: She denies fever, visual changes, sore throat, headaches, change in bladder or bowel habits, shortness of breath, or chest pain. She has had some menstrual irregularity this year that her gynecologist attributes to onset of menopause. She has also noticed some swollen lymph nodes in her neck and axillary regions. She has no other current problems.
9 Elements of ROS:
Constitutional, eye, ENT,
neurologic, GU, GI, respiratory,
CV, lymph

28. Patient unable to give History
Some patients can’t provide history
Unconscious
Intubated
Mentally ill
Mentally retarded
Certain illnesses (e.g., Alzheimers)
Intoxication
Document any known information from other sources EMTs or family, etc.
Document reason patient unable to give history

29. Physical Examination
The physical examination will play itself out based on the Nature of the Presenting Problem (NPP).
It is good medical practice to limit the examination of a patient with the complaint of a sore throat to that specific system.
In contrast, the examination on a woman in her child-bearing years complaining of abdominal pain may warrant an examination of several systems.

30. Nature of Presenting Problem (NPP)
Be guided by the NPP and your good judgement in deciding the extent of the physical examination.

31. Physical Examination Dictated: “Vitals stable.” = NO CREDIT
Dictated: “HEENT normal.” = NO CREDIT
Dictated: “Abdomen benign.” = NO CREDIT
Dictated: “Neck benign.” = NO CREDIT
None of the above hit on any of the bullet points in the Multi-system or Single Organ System Examinations.
See E&M Guidelines pages 14 & 15

32. Physical Examination Dictated: “Vitals stable.” = NO CREDIT
Rather: “Temperature 98.1; pulse 108; Respiratory rate 24.” Counts for 1 Bullet. (CONSTITUTIONAL)
Dictated: “HEENT normal.” = NO CREDIT
Rather: “Tympanic membranes within normal limits. Oropharynx is clear.” Counts for 2 Bullets. (HEENT)
Dictated: “Abdomen benign.” = NO CREDIT
Rather: “No organomegaly, masses or bruits.” Counts for 3 Bullet. (ABDOMEN)
Dictated: “Neck benign.” = NO CREDIT
Rather: “Supple, no adenopathy or thyromegaly.” Counts for 2 Bullets (NECK).

33. ① ②
PE: VS: wt 138 lbs, t 98.2, p 66, r 16 bp 110/70. Genl: NAD HEENT: EOMI, PERRLA. Anicteric. Oropharynx clear. TMs intact canals clear bilat. Neck: Supple w/thyromegaly, cervical node enlargement. Chest: Clear to auscultation. Heart: RRR. Abdomen: Non-tender and nondistended, no masses, rebound or guarding. Extremities: No cyanosis, clubbing or edema. ③ ④ ⑤ ⑥ ⑦ ⑨ ⑧ ⑩ ⑪ ⑫
①①① ⑬ ⑭

34. Level of Examination 14 bullets = Detailed Examination

35. How many bullets does it take?
Document 5 or less bullets and it is a Problem Focused Examination. (PF)
Document at least 6 bullets and you’ve achieved an Expanded Problem Focused Examination. (EPF)
Document at least 12 bullets and you’ve achieved a Detailed Examination. (DET)

36. Components of Medical Decision Making
Diagnoses and Treatment Options
Complexity of Data Reviewed
Risk
presenting problem
diagnostic procedures ordered
management options selected

37. Number of Diagnoses or Management Options
Assessment, clinical impression, or diagnosis
Initiation of, or changes in, treatment
Referrals made, consultations requested or advice sought

38. Medical Decision Making: 1) Diagnoses
just mentioning a condition is not enough, make an assessment for it to count.
Example 1: HTN
Improved Example 1: HTN well controlled with medication
Example 2: DM
Improved Example 2: DM controlled through diet and exercise

39. Medical Decision Making: 1) Management Options
In your Plan section, indicate how the problems are being addressed:
Example 1: ‘will cover options with patient’
Improved Example 1: patient is being referred to physical therapy

40. Number of Presenting Problems
Patients may present with many problems
Only count problems being addressed today
Include co-morbid conditions and complications
Count problems not being treated but which may have an impact on the treatment
Information may be found in
Chief Complaint
History of Present Illness
Review of Systems
Past Medical History
Assessment

41. Complexity of Presenting Problem
Problem self-limited or minor
Problems that would resolve without medical care
Problem is stable or improving
Stable for chronic illnesses that are controlled
Improved for acute illnesses that are getting better
Problem is worsening
Chronic illnesses that are uncontrolled or poorly controlled or that are progressing
Acute illnesses that are not responding to treatment
Relapses

42. New or Established Problem
New Problems
Problems that this provider has not seen before in this patient
Patient may have been treated by another provider
Patient may have had the condition for a long time
If patient has been seen for this problem by another provider in this group, problem is established
Established Problems
Problems already being treated by this provider

43. Management Options New problem with additional work-up planned
Additional workup includes
Laboratory studies
Radiology studies
Medicine studies
Consults

44. Medical Decision Making: 2) Data Reviewed
itemize lab results in your documentation
– "WBC elevated" or "chest x-ray unremarkable“
mention reviewing x-ray films brought in by patient

45. Medical Decision Making: 2) Data Ordered
note labs ordered and reason for ordering to establish Medical Necessity
rationale must be evident
note all diagnostic procedures ordered and the reason for ordering
must provide support in dictation as well as the order document

46. Medical Necessity
Link diagnoses and procedures by putting a small number in a circle next to the procedure and the same number next to its corresponding diagnoses
Order documents for labs, x-rays and other ancillaries can also be approached in the same way
See example of fee ticket: last tab in your handout ① ①

47. Medical Decision Making: 3) RISK
This is not something you write out such as “this was a high risk visit”…
This is derived from the entire note based on your documentation of the presenting problem, all diagnostic procedures ordered and your mention of the planned management options

48. RISK Risk associated with the presenting problem
Risk associated with any diagnostic tests ordered or performed
Risk associated with any treatment option selected
Use Table of Risk to choose a level pg 50
The auditor will be using this table in deciding the level risk for the visit

49. Level of Risk If risk of…
presenting problem,
diagnostic procedures, and
management options
are of different levels, pick the highest one
Your highest level of risk is your overall RISK
Information in Table of Risk is example
Although you may not refer to the table of RISK everytime you see a patient, this provides a primer or introduction to this very component

51. Selecting level of MDM 2/3
99201
99202
99212
99203
99213
99204
99214
99205
99215
Straightforward
Low
Moderate
High
# of Diagnostic and Management Options 1 2 3 4
Amt of Data to be Reviewed
Risk
Min(1)
Low(2)
Mod(3)
High(4)

52. Assessment and Plan:
Signs & Symptoms
Risk: Moderate; (acute illness with system symptoms)
Differential diagnoses not codeable
New problem additional workup planned
Assessment: Patient with nausea and vomiting for 12 hours. Food poisoning vs. allergic reaction vs. viral infection. She is also dehydrated and exhausted but unable to sleep.
Plan: We will start an IV and also give her something to relieve her nausea. We will continue to watch her to see if this will improve the situation and we may give her some Benadryl if she shows further signs of allergic reaction. We will also get a CBC and electrolyte panel. We will hold her here in the clinic until she is stabilized or we may have to admit her if this does not help her.
Mgmt option
Data ordered
Medical Decision Making: MODERATE

53. Selecting a Level of Care
Step one: Is patient NEW or ESTABLISHED
Step two: What kind of services is it? Outpatient / Inpatient / ER / Consultation / OTHER
Step Three: Evaluate levels of History, Examination and Medical Decision Making
Step Four: Select the level care taking care that the right number of components are met for the type of visit at hand.

54. Adding the Three Key Components
History
Examination
Medical Decision Making
New Patient
3/3
Established Patient
2/3
Should always include MDM

55. New Patient 3/3 Consultation 3/3
History
Problem Focused
Expanded Problem Focused
Detailed
Comprehensive
Examination
Medical Decision Making
Straightforward
Low
Moderate
High
Level of Care
99201
99241
99202
99242
99203
99243
99204
99244
99205
99245

56. Established Patient 2/3
History
Minimal Problem that may not require the presence of a physician
Problem Focused
Expanded Problem Focused
Detailed
Comprehensive
Examination
Medical Decision Making
Straightforward
Low
Moderate
High
Level of Care
99211
99212
99213
99214
99215