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The information below is based on CMS 1995 and 1997 guidelines. As of 1/1/2021, this information does not apply for E/M services in the outpatient or inpatient setting. Refer to History On or After 1/1/2021 for related information.

History Prior to 12/31/2020

  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. Reviewed 1/15/2021

  2. For comprehensive level services for which PFSH is required, is the term “no pertinent family history” sufficient documentation.

    Answer:
    At the comprehensive level of care, CMS considers family history to be essential and pertinent. 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. Revised 1/15/2021

  3. In the office/outpatient setting, what are the CMS documentation guidelines for who may elicit and document the patient’s history and how the provider may refer to previously recorded information in the medical record?

    Answer: As per CMS MLN Matters® MM11063: Summary of Policies in the Calendar Year (CY) 2019 Medicare Physician Fee Schedule (MPFS) Final Rule, Telehealth Originating Site Facility Fee Payment Amount and Telehealth Services List, CT Modifier Reduction List, and Preventive Services List, effective 1/1/2019, CMS modified previous rules relative to history discussion and documentation.

    “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.” Revised 1/19/2021

  4. For a comprehensive level of care, is it sufficient to document “family history noncontributory to patient condition, illness or injury” or “reviewed and noncontributory to condition, illness or injury?”

    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. Revised 1/19/2021
     
  5. When 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 family member or authorized patient representative?

    Answer:
    When the patient is unable to provide a history of the present illness it is permissible for the provider to obtain and document history obtained from the patient’s family member or authorized representative. The situation should be noted in the medical record along with the source from whom history was obtained. Revised 1/19/2021
     
  6. When history is not available due to 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. Revised 1/19/2021
     
  7. 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. Reviewed 1/19/2021
     
  8. 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. Reviewed 1/19/2021
     
  9. Is it permissible 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. Revised 1/19/2021

  10. 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. This rule applies to all situations in which a patient is seen for a previously arranged diagnostic procedure. Revised 1/19/2021
     
  11. 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. Reviewed 1/19/2021
     
  12. Do Medicare auditors count negative responses towards elements in the HPI?

    Answer: Both positive and negative responses on HPI questions are counted. Reviewed 1/19/2021
     
  13. 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. Reviewed 1/19/2021
     
  14. 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. Reviewed 1/19/2021 
     
  15. 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. Reviewed 1/19/2021
     
  16. 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. Reviewed 1/19/2021
     
  17. 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. Reviewed 1/19/2021
     
  18. 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. Reviewed 1/19/2021
     
  19. 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. Reviewed 1/19/2021
     
  20. 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. Reviewed 1/19/2021

  21. 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. Reviewed 1/19/2021

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History Prior to 12/31/2020
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