Begin Summer Training by Understanding the History Components of Evaluation and Management

  • Gretchen Dixon, MBA, RN, CCS, CPCP, ICD-10-CM/PCS Trainer
  • Volume 08 - Issue 2

Summer is the time to relax and catch up on to-do list items. This fits in especially for the elements of clinical documentation in the Evaluation and Management (E/M) visit levels, which need reviewing.

Now is the time to focus on this troubled topic of Evaluation and Management as they affect the accuracy score for your visit levels. Some may feel like this is drudgery in action again when there is a request of the provider to either clarify or add details into the clinical documentation. By tweaking your clinical information through adding details, you may bring forward those misplaced or partially forgotten nuggets of value (details relating to the patient’s current visit).

The OIG in their 2017 Work Plan continues to monitor the data regarding the E/M levels billed, knowing our weak spots  in the clinical documentation. The accuracy score after an audit of your E/M documentation will provide either a benchmark or validation of the compliance with clinical documentation expectations. These expectations are clearly documented by the Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) with their Evaluation and Management Service guide, which is updated annually, with August 2016 as the most recent.

Take time to review your accuracy score. If it is below 90%, have your coder take a sample of five of your medical records, reviewing to validate the level of clinical documentation in supporting the level of billed services.

NOTE: Even though there is complete clinical documentation by the provider, the documented information may not be sufficient or relevant to explain medical necessity to government attorneys and auditors.

Think of establishing 90% as a goal for your suggestions on how to improve your clinical documentation details, thus supporting the most accurate E/M visit level based on the patient’s medical necessity.

Before starting any type of documentation, THINK-N-INK: “If it is not documented, it was not considered or not done.” This sounds simple, but with today’s busy practice, staff may forget to document thoughts or misplace notes — paper scratch notes may get lost or, worse, documented on the wrong patient’s chart. It happens more frequently than you may expect.

Using the E/M history documentation components, this article will describe what providers need to document by thoroughly recording specific clinical information relevant to the reason for the visit. To reiterate, all clinical information must be relevant to the reason for the visit.

FOCUS: The documentation of each patient encounter should include:*
  • Reason for the encounter (chief complaint) and prior diagnostic test results
  • Assessment, clinical impression or diagnosis
  • Medical plan of care
  • Signature and date of provider
    *Per DHHS and CMS Evaluation and Management Services, August 2016

Within the history component are four elements that should be completed to their highest level of documented clinical information relevant to the reason for the visit: chief complaint (CC) or reason for the visit, history of present illness (HPI), review of systems (ROS) and past, family, social history (PFSH). The history components can be documented separately by element or inclusive in the History of Present Illness, as long as they can be specifically identified by the reader.

Chief Complaint (CC) Establishes the Need for Medical Necessity

The chief complaint, considered stage one of two in identifying medical necessity, sets the stage for which all other components in the medical record must be relevant. The CC should be a concise statement in the patient’s own words describing the reason for his or her visit with the health-care provider. There should always be a documented statement from the patient for each visit.

Ensure there are specifics when documenting the CC. Avoid valueless CCs such as “here for follow-up,” “patient returns today,” “patient here for appointment” or “here for check- up.” Ideally the CC could be the patient stating, “I am here for a follow-up about last week’s MRI or test,” which would be considered appropriate.

FOCUS: Ensure the chief complaint is documented in the patient’s own words to establish the medical necessity of the visit.

History of Present Illness (HPI) Establishes Medical Necessity

Stage two provides the level of details supporting the need for medical necessity of the visit. The HPI provides the details of the condition by asking pointed questions to elicit patient responses relevant to the chief complaint. A chronological description of details about how the patient developed his or her present illness, the HPI should include the eight specific elements below. Each element is provided with but not limited to the following examples.

1, Location— area of the body, such as "lower right leg", or the site of problem or condition, always include documenting laterality when appropriate

2. Quality— the patient's description of the specific attribute or character of the symptom or condition

                     a. Pain, described as sharp, dull, throbbing, stabbing, constant, intermittent

                     b. Acute, chronic, stable, worse, scratchy

3. Severity— intensity, degree, measure of the symptom or condition

                     a. Rate pain on a scale of 1 to 10

                     b. Pain description: "Worse I have ever had" "Not bad," "Severe," "Getting to the point where I can't stand it"

4. Duration— length of time the symptoms or conditions have been present

5. Timing— the onset of the symptoms, or when they occur

                     a. Worse at night

                     b. Hurts all the time

                     c. Only at night

                     d. Starts when I sit for more than an hour

6. Context— surrounding events

                     a. Where the patient is and what the patient is doing when the symptoms/problems begin

                     b. Situational stress-anxiety episodes due to life event

7. Modifying factors— what was done to alleviate the symptom or problem when it happens

                     a. Ice pack or heat applied

                     b. Antibiotic cream

                     c. Tylenol for pain

                     d. Must lay down

8. Associated signs and symptoms— additional signs and symptoms related to or part of the patient’s problem(s) that may not fit in any of the other categories


The HPI often lacks the amount of details describing the history of the present illness that external auditors are beginning to focus on. In the wound care environment, there needs to be a consistency of documented details on the past treatments, interventions and other medical care provided to the patient for the specific condition to include both positive and negative outcomes. It is this level of detail that supports the medical necessity and demonstrates the higher level of acuity, complexity of care and intensity of services the patient requires.

Now with the understanding of the importance of setting and establishing the medical necessity for the visit with the CC and HPI, it is vital to recognize that all the other components in the E/M must be relevant to both items. Copying and or pasting past clinical information does not always provide the relevancy for the visit. This process may actually be detrimental to the content of clinical information.

The HPI is one area in which your E/M visit level may be down-coded a level during an audit.

  • Establishing medical necessity with clear and accurate clinical documented details of the patient's problem.
  • Review current documentation process to improve by adding value to the clinical information, ensuring all eight elements are included.

Review of Systems (ROS)

The review of systems is another component where  external auditors are beginning to focus due to recognizing another area in which clinical documentation  is  weak when validating the E/M visit level. The ROS entails inquiries or questions concerning the system(s) directly related to the problem(s) identified in the HPI. This is a different interpretation from the past, when all systems were identified either by the patient completing a dedicated form or the ancillary staff asking questions of the patient and documenting the patient’s response.

NOTE: Never record the phrase “no known allergies” in the ROS for the allergic system. It belongs under the patient’s past medical history in the PFSH element.

The HHS and CMS Evaluation and Management Services (published August 2015 and 2016, respectively) notes on page 7: “ROS inquiries about the system directly to the problem(s) identified in the HPI and a number of additional systems.”

FOCUS: Ensure credit is only for those systems relevant to the problems identified in the HPI.

Past, Family, Social History (PFSH)

Although this element is usually documented only at the time of the initial visit, if a patient is on medications that may change between visits, the medication list must be updated. If a follow-up visit results in an E/M, then the medication needs to be recorded under the past medical history.

FOCUS: Although a wealth of information is recorded in the PFSH element, take credit only for the information that is relevant to the problem(s) identified in the HPI.

Any relevant medical updates such as tests, interventions, and procedures since the last visit need to be included in the documentation. Additionally, when a patient advises of “no known allergies,” this is always considered a part of the patient’s past medical history.

In the past, we have been accustomed to taking credit for everything documented in this section whether it is relative or not to the reason for the visit. As stated in the HHS/CMS Evaluation and Management Services documentation guide, however, documenters are specifically notified that the PFSH is a review of the medical, family and social history areas directly related to the problem(s) identified in the HPI. Auditors will remove credit for information not relevant to the medical problem in the HPI.

Synopsis of History Elements

As you read through the above history elements, you should have discovered two common threads that must be followed to avoid overreporting of an E/M visit level. The first is establishing and validating medical necessity, and the second is ensuring all elements documented are relevant to the identified problem(s) in the HPI for credit of this component supporting the reported E/M visit level.

Irrelevant information added through the electronic health record (EHR) by the automatic populating option of copying and pasting past information into these components is easily discoverable. Often providers do it to try to save time from having to document similar information. If an audit discovers the irrelevant clinical documentation, the visit level may result in a lower visit level. Is this activity worth the risk? The risk is not only overcoding a visit level but also possibly having a pattern discovered, which may require an extensive retrospective audit, possibly validating a pattern of overbilling visit levels resulting in false claims. Now you have entered the realm of compliance issues involving not only governmental payers but also third party-payers.

Third party-payers are increasing their audits, picking up on what Medicare has audited for years knowing E/M levels supporting clinical documentation has a deep weakness, resulting in anticipating overpayments to be refunded. (Refer to the Federal Register dated February 12, 2016, titled “Medicare Program: Reporting and Returning of Overpayments; Final Rule.”)

Please click on the links below to register for one of our five- week webinar series on clinical documentation improvement so your medical decision-making is supported when providing patient care.

July 19: billing-and-coding/204-essentials-of-icd-10-cm-coding-and- clinical-documentation-improvement-for-the-hyperbaric- team-5-day-series-4.html

Oct. 4: billing-and-coding/205-essentials-of-icd-10-cm-coding-and- clinical-documentation-improvement-for-the-hyperbaric- team-5-day-series-2.html



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Department of Health and Human Services, Centers for Medicare and Medicaid Services. Evaluation and Management Services. 2016 August.

Department of Health and Human Services, Centers for Medicare and Medicaid Services. Laws Against Health Care Fraud Resource Guide. 2015 September.

Department of Health and Human Services, Centers for Medicare and Medicaid Services. Medicare Fraud and Abuse. 2016 October. https:// MLNProducts/downloads/Fraud_and_Abuse.pdf

Department of Health and Human Services, Centers for Medicare and Medicaid Services. Medicare Program: Reporting and Returning of Overpayments; Final Rule. Federal Register 2016, Feb. 12:81(29).

Huey K. Documenting to support medical necessity. AAPC, October 2012. ce13-47e1-90c1-4907eba70dbd/6b9dc000-0897-4c24-9f4a-519e1f3ab372.pdf

Jensen PR. A refresher on medical necessity. American Academy of Family Physicians Management, 2006.

Maccariella-Hafey P. Understanding the history component of the E/M code

               -Part 1. AHIMA Codewrite. 2014December.

Maccariella-Hafey P. Understanding the history component of the E/M code

               -Part 2. AHIMA Codewrite. 2015

Optum. Evaluation and management coding advisor. 2013; p. 18-28.

US Departmentof Justice. Individual accountability for corporate wrongdoing. 2015, September 9.
Verhovshek J. 5 key points about the E/M history component. AAPC. 2014, March 3. history-component/

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About the Author

GRETCHEN DIXON, MBA, RN, CCS, is the owner of Professional Compliance Strategies (PCS), LLC, and consults on outpatient departments and physician services. She has provided revenue- cycle compliance audits of services with a focus on wound care department operations for more than 10 years. She holds several credentials including an MBA in healthcare management, an RN with a practicing license in New York, and 23 multistate licensure from Virginia, AHIMA Certified Coding Specialist (CCS), AHIMA ICD-10-CM/PCS Approved Trainer, and is an AAPC Certified Professional (Healthcare) Compliance Officer. A longtime internal healthcare auditor, Dixon identifies issues through audits of D, C, B (documentation, coding and billing) of provided services. The outcome of each audit determines the topics of education to be provided to the staff and physicians, as she proactively believes education is the key to having complete, accurate, and consistent documentation supporting reimbursement for billed services. If you are interested in her services, contact Dixon at This email address is being protected from spambots. You need JavaScript enabled to view it. or call 1-615-210-7476.

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