<p>POLICY: EVALUATION AND MANAGEMENT – HISTORY Policy Number: FIN – 2105 Page(s): 1 of 3 Approved by: Effective Date:</p><p>PURPOSE: Properly performing the necessary history and documenting it provides the necessary information to accurately choose the appropriate E/M code to bill the insurance carrier.</p><p>POLICY: </p><p>1. The history may be taken through a written history form or paperwork, or it may be obtained through a consultation by one of the staff or doctor. 2. Four components of the patient history:</p><p> a. Chief Complaint  Concise statement from the patient describing the symptom, problem, condition, or other factor that identifies the reason for the office visit.  Must be included on each and every patient encounter! b. History of Present Illness  Composed of the following descriptors:  Location  Quality  Severity  Duration  Timing  Context  Modifying factors  Associated signs and symptoms  Brief HPI includes 1 to 3 factors  Extended HPI includes 4 or more c. Review of Systems  Used to inventory the patient’s body systems and better define the problem, clarify the diagnosis, identify any necessary tests, or define a baseline.  Systems to possibly review:  Constitutional  Eyes  Ears, nose, mouth, throat  Cardiovascular  Respiratory  Gastrointestinal  Genitourinary  Musculoskeletal  Integumentary  Neurological  Psychiatric  Endocrine  Hematologic/lymphatic  Allergic/immunologic  Problem-pertinent ROS – only one system is reviewed  Extended ROS – review of 2 to 9 systems  Complete ROS – review of 10 or more systems  Must at minimum document positive and then state “all other systems are negative” d. Past, Family, and Social History  An overall look at the patient’s past medical history, as well as any social or familial factors that might influence present condition.  There are three elements of the PFSH:  Past History - Information about past injuries, operations, allergies, illnesses, current medications  Family History - Information about medical events in the patient’s family, such as diseases that may be hereditary or place the patient at risk. - At minimum, should include cancer, heart disease, stroke, diabetes, MS, and arthritis  Social History - Marital status - Occupational history - Use of drugs, alcohol, and/or tobacco (mandatory that ALL patients over the age of 13 that are seen 3 or more times be asked about these…and document the answers) - Level of education  “ Past Family History: Negative” is not adequate but “History of drug allergies is negative” would be adequate.  Pertinent PFSH – review of history area directly related to the problem identified in the HPI. Must document at least ONE specific item from any of the three history areas.  Complete PFSH – review of TWO or all THREE history areas depending on the category E/M service. Services that include a comprehensive assessment/reassessment of the patient require a review of all three areas. A review of two of the three history areas is sufficient for all other services.</p><p>3. Four levels of history based on the lowest classification of any of the above listed components:</p><p> a. Problem – focused  HPI = Brief  ROS = N/A  PFSH = N/A b. Expanded Problem – focused  HPI = Brief  ROS = Problem pertinent  PFSH = N/A c. Detailed  HPI = Extended  ROS = Extended  PFSH = Pertinent d. Comprehensive  HPI = Extended  ROS = Complete  PFSH = Complete</p>