A Brief History
Although the latter method is formally included in Medicare’s documentation guidelines and accepted by some Medicare contractors (e.g. Highmark, WPS), be aware that it is not universally accepted.5,6
The four recognized levels of history are problem-focused, expanded problem-focused, detailed, and comprehensive. The number of elements documented in the progress note determines level selection. The physician must meet all of the requirements in a particular level of history before assigning it (see Table 2). If the documentation is insufficient, the assigned level represents the least-documented element.
For example, if physician documentation includes four HPI elements, eight ROSs, and a comment in each of the PSFHs, credit is given for a detailed history. If submitting a claim for initial hospital care, the history supports 99221.—CP
Documentation involving the ROS can be provided by anyone, including the patient. The physician should reference ROS information that is completed by individuals other than residents or NPPs during services provided under the Teaching Physician Rules or Split-Shared Billing Rules. Physician duplication of ROS information is unnecessary unless an update or revision is required.
Past, family, and social history (PFSH). The PFSH involves data obtained about the patient’s previous illness or medical conditions/therapies, family occurrences with illness, and relevant patient activities. The PFSH could be classified as pertinent (a comment on one history) or complete (a comment in each of the three histories). The physician merely needs a single comment associated with each history for the PFSH to be regarded as complete. Refrain from using “noncontributory” to describe any of the histories, as previous misuse of this term has resulted in its prohibition. An example of a complete PFSH documentation includes: “Patient currently on Prilosec 20 mg daily; family history of Barrett’s esophagus; no tobacco or alcohol use.”
Similar to the ROS, PFSH documentation can be provided by anyone, including the patient, and the physician should reference the documented PFSH in his own progress note. Redocumentation of the PFSH is not necessary unless a revision is required.
PFSH documentation is only required for initial care services (i.e. initial hospital care, initial observation care, consultations). It is not warranted in subsequent care services unless additional, pertinent information is obtained during the hospital stay that impacts care.
Considerations
When a physician cannot elicit historical information from the patient directly, and no other source is available, they should document “unable to obtain” the history. A comment regarding the circumstances surrounding this problem (e.g. patient confused, no caregiver present) should be provided, along with the available information from the limited resources (e.g. emergency medical technicians, previous hospitalizations at the same facility). Some contractors will not penalize the physician for the inability to ascertain complete historical information, as long as a proven attempt to obtain the information is evident.
Never document any item for the purpose of “getting paid.” Only document information that is clinically relevant, lends to the quality of care provided, or demonstrates the delivery of healthcare services. This prevents accusations of fraud and abuse, promotes billing compliance, and supports medical necessity for the services provided.
Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center in Philadelphia. She is faculty for SHM’s inpatient coding course.
