billing & coding
Determining Level of History
This column is the first in a series on evaluation and management coding.
CARLA MACK, O.D.

The New Year seems like a perfect time to hone our coding skills. Before you determine the level of the evaluation and management service you provide, you must determine the level of each of the following three key components: history, examination and decision making. This is the first in a series of articles on determining the appropriate levels of the three key components of evaluation and management services. This month, we'll focus on history.

Three elements

When determining the history level, consider these three elements:

1. Chief complaint and history of the present illness

2. Review of systems

3. Past, family and/or social history.

The first element, or chief complaint, is the patient's reason for the visit, often recorded in his own words. Describe the history of this presenting illness (HPI) by location, quality, severity, timing, context, modifying factors and associated signs and symptoms.

The second element, the review of systems (ROS), is important for differential diagnoses and often contributes to baseline examination data. When you document any of the 14 systems in ROS, include the signs and symptoms experienced by the patient (see the chart below).

The third element to the history has three components: the patient's past history, the patient's family history and the patient's social history (see the "History Elements" chart below).

Choosing the level

The chief complaint, nature of the presenting problem and new or established status often contribute to the amount of history you gather. The information you document in the medical record determines the level of history.

The table below serves as a reference tool for efficient history level determination. Your documentation must satisfy all the require- ments for each history level to claim that level. For example, if you document the chief complaint and one to three elements of the HPI, then you have a problem-focused history. If you document the chief complaint, one to three elements of the HPI and one ROS, that's an expanded, problem-focused history. A detailed history must include at least four elements from the HPI, at least two ROS and at least one item from one area of the patient's past, family or social history.

Use the tables here in conjunction with your medical record to determine the level of history efficiently. Avoid guessing, which will lead to under- or over-coding.

DR. MACK IS DIRECTOR OF CLINICS AT THE OHIO STATE UNIVERSITY COLLEGE OF OPTOMETRY. SEND E-MAIL TO CMACK@OPTOMETRY.OSU.EDU.