The History and Physical

Your Presentation of the Patient to the Payer
by AJ Riviezzo, MBA
We have been noting, for several years now, the importance of documentation to ensure your practice can survive an audit. We now have a real life customer that has been on the receiving end of a ZPIC audit. The key issue upon which the audit rested was indeed the History and Physical documentation.

While this practice had been performing a more than sufficient examination of their patients, the data was primarily contained in a patient completed form and a physician completed form with minimal narrative elements. It was this lack of narrative report that deemed the documentation as insufficient to support the recommended course of treatment. In essence, while the data was obtained it was not verbalized in a way that Medicare’s audit team would accept as appropriate.

Whether or not you are writing your own History and Physicals or using an EMR such as StreamlineMD or Sonosoft, there are some essential components that must be included in your report. Medicare has detailed three key components. These are:

1. History – The history must contain a Chief Complaint, a history of the present illness, a review of systems (ROS) and a past family and social history (PFSH). The extent of the above, which is obtained and documented, is dependent upon clinical judgment and the nature of the presenting problem. In other words, the documentation needs to clearly support why you are treating the patient.

The patient self-report elements (ROS and PFSH) need to be incorporated into your History and Physical by reference which both acknowledges the report was reviewed and considered regarding the patient’s potential course of treatment.

Per CMS guidelines, “The Chief Complaint is a precise statement describing the symptom, problem, condition, diagnosis or other factor that is the reason for the encounter. Documentation requires that the medical record should clearly reflect the Chief Complaint.” Under the Chief Complaint you should list the history of the present illness (HPI). Again per CMS guidelines, “The HPI is a chronological description of the development of a patient’s present illness from the first sign or symptom or the previous encounter to the present. It contains the following elements: location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms.” For phlebology, you should describe four or more of these elements so as to include conservative therapy attempts.

It is this section in which most physician’s documentation appears to fall short. We strongly recommend performing at least a self audit of this section of your H and P.

2. Examination – A standard examination should be performed including vital signs, general appearance, cardiovascular system, skin, and each extremity at a minimum. If the body area or organ system is normal, a notation indicating negative or normal is sufficient. However, if the organ system or body area is abnormal or symptomatic you must describe your findings in sufficient detail. For the phlebology practice you need to ensure robust documentation of any findings that pertain to the CEAP (Clinical, Etiologic, Anatomic, Pathophysiologic) classification system for venous disease.

3. Medical Decision Making – For each encounter, an assessment, clinical impression or diagnosis should be documented. This may be stated or implied in documented decisions regarding the patient’s care management plan or needed further evaluation. If a diagnostic service (test or procedure) is ordered, planned, scheduled, or performed at the time of the office visit, the type of service should be documented. For a phlebology practice, this means the diagnostic ultrasound needs to be noted as ordered and why. The results of any diagnostic tests should be documented in the H and P as well.

If you are performing the diagnostic ultrasound prior to performing the H and P, the decision for ordering the diagnostic test and the results should be clearly documented.

When you are noting the plan of care, the documentation must also contain a mention of any risk of significant complications, morbidity or mortality. A reference to ulcerations or DVT’s would be appropriate in this section along with any patient specific risks.

A practice needs to ensure these elements are met in their documentation. While this is time consuming and not terribly exciting, it is much better to spend that little extra effort now then when facing an audit. We again recommend you perform a self-audit or have someone external review your documentation to ensure compliance.