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  1. If the patient is seen frequently for chronic condition(s)/management of multiple medications and the encounter essentially results in the same ROS and exam findings, is it acceptable to indicate under ROS and exam same as noted in prior visit on DD/MM/YYYY?

    Answer:
    As per updated guidelines released in the CMS 2019 Final Rule, the provider may reference information obtained and documented in a previous encounter, with the expectation that the provider will note the date of the prior record and a review and update to the previously recorded note. Revised 4/17/2019

  2. Please clarify whether or not NGS would accept “no pertinent family history” as sufficient documentation to support family history at the comprehensive level of service.

    Answer:
    At the comprehensive level of care, NGS does not consider family history to be nonpertinent in any context. It is expected that a family history include the minimal elements, which are the age of parents and siblings (if alive) and their current health status, or their age and cause of death if they are deceased. Additional elements may be added as appropriate. Updated 7/24/2018

  3. What are the CMS documentation guidelines for who may elicit and document the patient’s history, including ROS, HPI and PFSH, and how the provider may refer to previously recorded information in the medical record?

    Answer: As of 1/1/2019, CMS has modified previous rules relative to history discussion and documentation. As per CMS MLN11063, effective on 1/1/2019:

    “For established patient office/outpatient visits, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed. Practitioners should still review prior data, update as necessary and indicate in the medical record that they have done so.

    CMS is clarifying that for E/M office/outpatient visits, for new and established patients for visits, practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information.” Updated 2/7/2019

  4. Is documentation of “family history noncontributory to patient condition, illness or injury” or “reviewed and noncontributory to condition, illness or injury” sufficient to support family history?

    Answer:
    Family history is a required element of documentation at the comprehensive level of service. When the patient is unable to provide a history, due to his/her clinical condition, this fact must be documented in the medical record. In addition, the provider must document all attempts to elicit history from family members, EMS and ambulance attendants and also prior medical records. Updated 8/29/2017
     
  5. If a patient is not able to provide a history, due to altered mental status or physical impairment, can credit be allowed when history is elicited from a patient’s spouse?

    Answer:
    When a spouse provides history, credit may be taken for obtaining history for someone other than the patient. Updated 8/29/2017
     
  6. Can a specific negative family history be used to satisfy the family history? Example: family history-negative for diabetes mellitus.

    Answer:
    At the detailed level of care, one pertinent component of  PFSH is required, and the example provided here would meet that requirement. At the comprehensive level of care, a complete PFSH is required. Updated 8/29/2017
     
  7. Is the statement, “medications reviewed” enough to get credit for past history?

    Answer:
    Past history includes at a minimum, a review of the patient’s medical and surgical history. Review of medications alone does not suffice as a past history. Updated 8/29/2017
     
  8. When an element of history applies to both the HPI and ROS, can that element be counted toward both aspects of history? For example, if a patient presents with a recent history of nausea/vomiting, can these symptoms be counted within the HPI and in the ROS for the GI system?

    Answer: When an element of history applies to more than one aspect of history, it may be recorded and counted within both. In the example above, the patient’s GI complaints are relevant to the HPI and also the GI ROS and may be counted toward both aspects. Updated 6/9/2017
     
  9. Can a single HPI element be counted twice for the same encounter if it is related to two different complaints? Example: For “location” patient complaining of abdominal pain in the low right quadrant and left knee pain.

    Answer:
    HPI elements can be counted as often as they apply to presenting complaints. Updated 6/9/2017
     
  10. Is it ok to use the chief complaint for an HPI element (if it is repeated by the provider in the HPI)?

    Answer:
    Yes, the chief complaint may be repeated within the HPI if elicited by the performing provider. Updated 6/9/2017
     
  11. Can a nurse document the chief complaint?

    Answer:
    The nurse may document the chief complaint but the record must demonstrate the provider’s review and acknowledgement of the complaint. Updated 6/9/2017
     
  12. Can a provider identify the chief complaint within the HPI?

    Answer:
    The provider may corroborate or restate the chief complaint within the context of the HPI. Updated 6/9/2017
     
  13. When a patient is unable to provide a history (e.g., patient is unconscious or intubated), the provider may take credit for a complete history if he/she documents all attempts to elicit history. Does this apply to physical examination?

    Answer:
    Unless an examination is performed and documented, it cannot be included as a required element of an E/M service. Updated 6/9/2017

  14. Can “screening colonoscopy” be a valid chief complaint?

    Answer:
    “Screening colonoscopy” is not a valid chief complaint; an E/M visit prior to a colonoscopy is not medically necessary unless the patient has a clinical condition or complaint that would warrant separate evaluation and care prior to the scheduled procedure. Updated 6/9/2017
     
  15. When HPI, ROS and PFSH are not available due the patient’s condition, can a detailed or comprehensive level of care be achieved and documented?

    Answer:
    A detailed or comprehensive level of care may be billed when patient history is not obtainable. Documentation would need to reflect the clinical reason that history cannot be obtained (e.g., patient unresponsive, comatose, disoriented, etc.). The medical record should also reflect any and all attempts made by the provider to elicit history from available family or significant others, from prior electronic and paper medical records, from eyewitnesses to an injury or from police and ambulance personnel. Updated 6/9/2017
     
  16. Does a ten “point” review of systems suffice as a complete review of systems?

    Answer: A review of ten systems within an ROS is considered a complete or comprehensive ROS. Updated 6/9/2017
     
  17. Do Medicare auditors count negative responses towards elements in the HPI?

    Answer: Both positive and negative responses on HPI questions are counted. Updated 6/9/2017
     
  18. When a family history is noncontributory, what is the best means of documenting that fact?

    Answer: A family history may only be assessed as “noncontributory” for a level of service for which it is not required. For comprehensive level of service, family history is considered an essential element and cannot be considered “noncontributory.” Updated 6/9/2017
     
  19. In obtaining a comprehensive HPI for a patient with multiple presenting complaints, does each complaint require documentation of four HPI elements?

    Answer: HPI elements are evaluated cumulatively. Documentation for each complaint should reflect the clinically appropriate information. Updated 6/9/2017
     
  20. Can the chief complaint be a service, such as a lab result or INR test, rather than a specific condition or sign or symptom?

    Answer: The chief complaint may be stated as “Patient is here to discuss abnormal laboratory (including INR) results.” In that situation, the patient’s visit with the provider may not include a history or examination; if the provider is meeting with the patient for discussion/ counseling, the visit may be coded based on time spent in counseling. Please note: if there are no laboratory results requiring discussion and results could have been communicated via telephone, a visit may be considered medically unnecessary. Updated 6/9/2017
     
  21. What documentation requirements does NGS look for regarding HPI and the status of three chronic conditions? How does the inclusion of chronic conditions affect scoring for MDM?

    Answer:
    When documenting the status of three chronic conditions in an HPI, the documentation should include the three conditions and whether they are stable (patient reports no change in related symptoms) or the patient is now reporting a change in symptoms or complaints. Updated 6/9/2017

    The CMS TOR allows for an assessment of moderate risk when the examiner has to consider two or more stable, chronic illnesses in the patient’s health profile. Although there may be no current complaints or findings relative to the chronic conditions, the examiner may elect to include their presence in treating the current complaint, since they may represent potential impact to the POC. Updated 6/9/2017
     
  22. Are there a minimum number of systems a provider must document in the ROS before adding “all others negative” for a complete ROS?

    Answer:
    An ROS of ten systems is necessary for a comprehensive history, but there is no minimum number of systems for which the examiner must document historical information before adding “all others negative.” The number of systems reviewed in the ROS should correlate to the systems associated with the patient’s presenting complaint(s). For example: An ROS for a patient who presents with chief complaint of chest pain, shortness of breath and lower extremity edema and extreme fatigue would require of review of multiple systems, while no ROS may be medically necessary for a patient who presents with a traumatic injury to a finger. The notation of “all others negative” may be appropriate when multiple systems have been reviewed, for medically necessary reasons, but for which the patient reports no relevant events or symptoms. Updated 6/9/2017
     
  23. When documenting an ROS, should edema be counted under cardiology, orthopedics or nephrology?

    Answer:
    An ROS notation of edema should be counted under the system with which the examiner would associate the edema, which would be inferred by the presenting complaint or known diagnoses. In a patient with cardiac or renal issues, edema would be counted under the cardiovascular system, while in a patient with orthopedic injury, edema would be counted under musculoskeletal system. Updated 6/9/2017
     
  24. Please confirm the extent of PFSH needed for new versus established patient visit at the comprehensive level.

    Answer:
    According to the CMS Evaluation and Management Services Guide, (3 MB) the documentation requirements for a complete PSFH are based on the category of E/M code.
    1. New Patient: (office, hospital, home visit): 3/3 elements
    2. Established Patient: (office, hospital, home visit): 2/3 elements Updated 6/9/2017

  25. Can a provider bill for a comprehensive history when the patient is unresponsive? If the medical record indicates the patient is “unresponsive,” in a “coma,” or “extremis of age” can medical inference be used to determine a ROS is unobtainable?

    Answer:
    A comprehensive level of care may be billed when patient history is not obtainable. Documentation would need to reflect the clinical reason that history cannot be obtained (e.g., patient unresponsive, comatose, disoriented, etc.). The medical record should also reflect any and all attempts made by the provider to elicit history from available family or significant others, from prior electronic and paper medical records, from eyewitnesses to an injury or from police and ambulance personnel. Updated 6/9/2017
     
  26. For the family history, will NGS reviewers accept “noncontributory”?

    Answer:
    The family history includes the age of parents (if alive) and their current health status or their age and cause of death if they are deceased. It also includes the age of each sibling (if alive) and their current health status or their age and cause of death if they are deceased. This is expected under family history and is the minimal amount that is needed. It is not possible to claim this is “noncontributory” unless the information is not medically necessary, in which case the PFSH element should not be counted toward the level of E/M service. Updated 6/9/2017
     
  27. Is it permissible to refer to an earlier note’s PFSH and ROS when seeing an established patient in the office? If so, what are the documentation requirements?

    Answer:
    Yes, the provider may reference an earlier PFSH and ROS, but must indicate the date of the earlier information, document his/her review and whether interval changes have occurred. Updated 6/9/2017
     
  28. Does the statement “three healthy children” suffice as documentation of social history?

    Answer:
    “Three healthy children” is part of the patient’s family, not social, history. Social history includes an age appropriate review of past and current life activities. As such, the expectation is that social history includes commentary on living arrangements (“lives with his wife and grown son”), drug and alcohol usage (“reports occasional use of marijuana and consumes two‑four alcoholic drinks per week”), smoking history (“has never smoked cigarettes”) sexual history (“remains sexually active with his wife of 30 years” or “is homosexual and sexually active with his committed partner of 15 years”) and any other lifestyle factors that might impact the patients physical and/or psychological health. Updated 6/9/2017
     
  29. Will NGS accept HPI elements from more than one condition/complaint to be counted cumulatively?

    Answer:
    Yes, credit will be given on HPI elements from more than one condition, not necessarily grouped per condition. Updated 6/9/2017
     
  30. If the patient is seen frequently for chronic condition(s)/ management of multiple medications, and the encounter essentially results in the same ROS and exam findings, is it acceptable to indicate under ROS and exam same as noted in prior visit on DDMM/YYYY?

    Answer:
    As per updated guidelines released in the CMS 2019 Final Rule, the provider may reference information obtained and documented in a previous encounter, with the expectation that the provider will note the date of the prior record and a review and update to the previously recorded note. Revised 4/17/2019
     
  31. When reviewing the patient’s PFSH, is it acceptable to accept this information from a previous visit by another clinician, e.g., PCP referring to specialist? Is the answer different if they are on the same EMR versus a different EMR?

    Answer:
    The PFSH from a prior visit is acceptable, only when there is an indication that the information has been reviewed with the patient on the current DOS and amended as necessary. The use of one EMR software product versus another is not relevant. The note must also reference the date and location of the earlier entry. Updated 6/9/2017
     
  32. Can I use three chronic problems to complete an extended HPI (as allowed under the 1997 guidelines) and still use the 1995 physical exam?

    Answer:
    For reporting services to Medicare furnished on and after 9/10/2013, you may use the  1997 Documentation Guidelines for Evaluation and Management Services (595 KB) for an extended HPI along with other elements from the 1995 Documentation Guidelines for Evaluation and Management Services. to document an E/M service. Updated 6/9/2017
     
  33. Is documentation of the most clinically relevant systems with a notation “all other systems reviewed and are negative” permissible to qualify for a complete (ten system) ROS?

    Answer:
    Yes, entries relative to the patient’s current clinical status are expected and “all others reviewed and negative” can be used for other systems. Updated 6/9/2017
     
  34. Can a provider review his/her own previous notes and summarize the findings, taking credit for “review and summation of old records?”

    Answer:
    This would be permissible only if the patient was no longer considered “established” to the provider, i.e., a period of three years or longer had passed since the patient was last seen by the provider or a same-specialty group member. Updated 6/9/2017
     
  35. Should a provider take credit for negative HPI elements? As an example, if a patient is questioned about modifying factors and reports none, can credit be taken for this HPI element?

    Answer:
    Yes, as long as this is documented in the record. Updated 6/9/2017

  36. When documenting allergies, is credit allowed as an element of past medical history or is this counted as part of the ROS (allergic/immunologic) or both?

    Answer:
    Such an entry could be counted under both past medical history and ROS. Updated 6/9/2017

  37. What are the CMS documentation guidelines for who may elicit and document the patient’s history, including ROS, HPI and PFSH, and how the provider may refer to previously recorded information in the medical record?

    Answer:
    As of 1/1/2019, CMS has modified previous rules relative to history discussion and documentation. As per CMS MLN11063, effective on 1/1/2019:

    “For established patient office/outpatient visits, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed, and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed. Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so.

    CMS is clarifying that for E/M office/outpatient visits, for new and established patients for visits, practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information.” Updated 2/7/2019

  38. What are the CMS documentation guidelines for who may elicit and document the patient’s history, including ROS, HPI and PFSH, and how the provider may refer to previously recorded information in the medical record?

    Answer: As of 1/1/2019, CMS has modified previous rules relative to history discussion and documentation. As per CMS MLN11063, effective on 1/1/2019:

    “For established patient office/outpatient visits, when relevant information is already contained in the medical record, practitioners may choose to focus their documentation on what has changed since the last visit, or on pertinent items that have not changed and need not re-record the defined list of required elements if there is evidence that the practitioner reviewed the previous information and updated it as needed. Practitioners should still review prior data, update as necessary, and indicate in the medical record that they have done so.

    CMS is clarifying that for E/M office/outpatient visits, for new and established patients for visits, practitioners need not re-enter in the medical record information on the patient’s chief complaint and history that has already been entered by ancillary staff or the beneficiary. The practitioner may simply indicate in the medical record that he or she reviewed and verified this information.” Updated 2/7/2019

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