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When established patients come in for a glaucoma evaluation, they often don’t report any related factors, such as changes in vision. So your staff may assert that there is not much to document for the History of the Present Illness. Indeed, that’s what happened in the example of patient X, below. But the second example, patient Y, demonstrates how full documentation of the history and exam enables you to report a higher level of E&M code.
Patient X—Incomplete Chart
History. “Chief complaint: Glaucoma check OU.” The History of the Present Illness (HPI) has one element (location), which makes it a “brief” HPI. Neither the Review of Systems (ROS) nor the Past, Family and Social History (PFSH) is documented. Despite the “brief” HPI, the absence of an ROS and PFSH means the chart only supports a “problem focused” history (see table).
Examination. Four elements of the exam are documented, which means the chart supports a “problem focused” exam (one to five elements).
Medical decision-making. The chart documents that the patient should continue with the current treatment plan and return in four months, or earlier if necessary. Medication type and dosage were not documented. This chart supports a “straightforward” level of decision-making.
E&M code. The combination of a “problem focused” history, “problem focused” exam and “straightforward” medical decision-making supports the use of E&M code 99212.
Patient Y—Fuller Documentation
History. “Chief complaint: Pt presents for glaucoma evaluation follow-up OU [location]. Pt states compliant with drops since prescribed three months ago [duration]. No eye or lid irritation [context]. Vision seems stable [quality]. Eyes comfortable majority of time [associated signs and symptoms]. ROS: Eyes. Past History: Glaucoma medication detailed to include dosage and time of last application.” The HPI has five elements (location, duration, etc.), and that places it within the range of an “extended” HPI (four to eight elements). As for the ROS, only the system in the HPI is reviewed, and that means it is a “problem pertinent” ROS. The PFSH includes Past History but not Family or Social Histories, making it a “Pertinent” PFSH. This combination of HPI, ROS and PFSH supports a “problem expanded” history (see table).
Examination. Nine elements were documented, which means the exam falls within the range of a “detailed” exam (nine to 12 elements).
Medical decision-making. As with the previous patient, the chart supports a “straightforward” level of decision-making.
E&M code. The combination of a “problem expanded” history, “detailed” exam and “straightforward” level of decision-making supports the use of E&M code 99213.
TYPE OF HISTORY. The HPI, ROS and PFSH for patients X (red) and Y (yellow) are circled. When a row has duplicates (as with HPI’s “Brief” and “Extended”), you circle the one to the right. For each patient, the circle farthest to the left determines the type of history—“focused” for patient X and “expanded” for patient Y.