Understand the role of associated signs and symptoms

Q: When assessing the associated signs and symptoms during a patient’s history of present illness (HPI), how do negative answers affect the documentation?

A: Negative responses can count toward the history of present illness (HPI) just as they do toward Review of System (ROS) questions.

Credit is given for the gathering of HPI information, not the patient’s response(s). So the patient’s answers, whether positive or negative for particular signs and symptoms, help provide the puzzle pieces that direct what ROS, exam, and/or diagnostic test(s) will be medically relevant to determine the patient’s diagnosis(es).

A clinician’s impressions formed during the beginning of a patient visit may lead to questioning about additional signs or feelings.  A provider may ask patients directly about “pertinent positives and negatives,” such as diaphoresis (marked sweating) associated with indigestion or chest pain; weakness and hunger in patients with diabetes; or blurring vision accompanying a headache. Generalized symptoms, such as chills or fever (and the degree) or overall weakness are often relevant to many conditions.

The blend of this information obtained helps a provider understand a clear picture of the patient’s self-described problem(s).

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For even the highest level of Evaluation and Management (E/M) code, an extended HPI, which requires four elements, is all that is needed to support the code level.  Therefore, if additional elements are documented in the HPI, credit can be given in the ROS.

Many times in these cases, the associated sign(s) or symptom(s) are credited in the ROS because they can be associated with specific systems of the body.

Q: Can you please tell us about the new policy for student documentation?  Does the physician still need to re-document the student’s work in order to use it to bill?

A: According to MLN Matters (number MM10412) implemented on March 5, 2018, CMS is revising the Medicare Claims Processing Manual to update policy on E/M documentation for teaching physicians. Teaching physicians will be allowed to simply verify the student medical record documentation utilized toward the level of E/M services, rather than re-documenting the work. 

Students may document services in the medical record. However, the teaching physician must verify in the medical record all student documentation or findings, including history, physical exam, and/or medical decision making. 

According to MLN Matters, the teaching physician must personally perform (or re-perform) the physical exam and medical decision making activities of the E/M service being billed, but may verify any student documentation of them in the medical record, rather than re-documenting this work.  This cuts down on the teaching physician’s time documenting.