Coding Corner: ICD-10-CM: The well-documented patient history

July 01, 2015
Area(s) of Interest: Patient Care Practice Management 

CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.   

Accurate coding—and optimal reimbursement—rest on the strength of the provider’s documentation. One commonly under-documented element is the patient history, but this is a deficiency that’s easy to avoid, if you follow four steps. 


1. Document the patient’s chief complaint. Every encounter must have a chief complaint, or a reason that the patient is seen. The provider must personally document the chief complaint, even if the patient or a staff member previously recorded the reason for the visit.


The chief complaint is always a problem. “Follow-up” is not a chief complaint. If the patient doesn’t have a problem (e.g., well patient check-up), the service is preventive.


2. Describe a history of the chief complaint. The history must be relevant to the presenting problem(s), and should seek to answer these questions:


  • Location: Where is the problem?
  • Quality: How would you characterize the problem?
  • Severity: How bad is the problem?
  • Duration: How long has the problem bothered you?
  • Timing: How often does the problem bother you?
  • Context: Is the problem associated with any particular event or action?
  • Associated signs/symptoms: Have you noticed any other symptoms since this problem started to bother you?
  • Modifying factors: Have you done anything to make the problem better/worse?

Just as the provider must document the chief complaint, he or she must personally document the history of current illness. Copying the nurse’s notes, for instance, is not appropriate.


3. Demonstrate a review of pertinent body systems. The “review of symptoms” (ROS) is the patient’s positive and negative responses about his or her experiences with symptoms. Providers should indicate as “positive” for symptoms any body system(s) that pertain to the chief complaint. All systems that are “positive” for symptoms, and those with “pertinent negatives” (negative responses where you would expect to see a “positive” response for symptoms) should include at least a brief explanation. Avoid blanket statements, such as “all systems unremarkable.”


The provider does not have to record the ROS. For example, ancillary staff may obtain the ROS, or you may ask the patient to complete a questionnaire or checklist. If the ROS is obtained on a separate form, the provider should sign and date the form to certify that he or she reviewed the information, and that the information is germane to the current visit.


4. Be brief, and be consistent. When relevant, you may document additional patient information supplied by a family member or caregiver. But in all cases, quality of documentation matters more than quantity. Many services (appropriately) will include a review of the patient’s past medical history, family medical history, and social history (e.g., is the patient married, employed, a smoker, etc.); however, details that do not pertain to the current visit or otherwise inform the provider’s medical decision-making for that visit detract from, rather than enhance, the record.


Finally, providers must ensure that documentation is internally consistent. Contradictory data is a common error. For example, the chief complaint may state one reason for the visit, but the history of present illness may detail a different problem.


Providers may not be able to meet all of the above requirements for all patients (e.g., there may be a language barrier, or the patient may be unconscious or otherwise uncommunicative). In such cases, the provider should document the circumstances, and explain that he or she was unable to obtain the information from the patient or other source. 



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