Seeing the “Gray” in Evaluation and Management Coding – Chief Complaint and History of Present Illness

Being able to see and audit the "gray" areas of E/M coding is what separates coding professionals from other coders. It’s human nature to want absolute truth in all we do. But the savvy coder knows that especially when it comes to coding E/M services, there are few absolutes.

As with all areas that are open to interpretation, we owe it to our practitioners and ourselves to be deliberative and consistent with our approach. The question I ask myself, as not only a coder/auditor but also as a coding consultant/educator to practitioners, is: "How can I educate practitioners to make the requirements clearer and consistent to apply and follow?" Let’s face facts--most practitioners did not go into medicine to learn how to code. We, as coders, have to remember that the medical record is primarily a patient care tool and then a reimbursement tool. Rather that burden practitioners with remembering all nuances (nuisances) related to coding I recommend defining the gray areas and determine how you will interpret them, then educate your providers and hold them to that criteria.

Here are a few of the common gray areas related to History of Present Illness (HPI) documentation with CMS guidance and how I, as a simple coder, interpret the gray:

Chief Complaint (CC): Both the 1995 and 1997 E/M Documentation Guidelines indicate that the CC is usually in the patient’s own words. In my experience that is often the case when the patient presents for an acute visit (stomach ache, runny nose, etc), but difficult and cumbersome to do when chronic illnesses are the reason for the visit. We all know that “follow up” is not sufficient documentation for a CC; but from a practical perspective I feel that a brief statement from the practitioner indicating why they are seeing the patient may support the documentation of a CC.

HPI: Update of 3 Chronic Illnesses: One of the common questions related to this element of HPI is, "can it be used for both the 1995 and 1997 Guidelines?" Updating chronic illnesses was introduced in the 1997 Guidelines and it is still erroneously assumed that they may only be used if the 1997 Guidelines are used. Many MACs (Carriers) have weighed in over the years; as more recently CMS has also indicated in “Evaluation and Management Service Guide” that this criteria may be used for either Guideline.

So what qualifies for the update of a chronic illness?

--Not sufficient: patient has DM, HTN and Hyperlipidemia.

--Meets criteria: patient has been a well controlled diabetic for the last year with oral meds and exercise, HTN was elevated at the last visit but home BP monitoring shows good control and last total cholesterol showed HDL/LDL at target.

Can you use the same information more than once? There is much debate amongst coders and auditors related to this and CMS has never definitively answered the question.

Here’s a scenario to consider: Patient complains of back pain for the last week worse at night, tingling down his legs, not relieved by ibuprofen, comes and goes with activity. Can “back pain” be used as both a chief complaint and location? What about quality or a musculoskeletal review of symptoms (ROS)? In my opinion we need to use caution. Remember we may not be the only people reviewing this information. My preference is to count the information only once but if the same info is documented in different places I would count it as a different element, if possible.

I know I’ve only scratched the surface related to the shades of gray and I have only discussed HPI. I would love to hear how you would or have handled some of these issues. Next time we will discuss more of History’s gray areas with a discussion of ROS and past, family, social history.

Written by: Laurie Desjardins, Senior Manager in the Healthcare Management Consulting Division of Baker, Newman and Noyes.