By Alice Anne Andress

A prior article of mine, “Documenting a Solid H&P, Part I,” covered the importance of good solid documentation and the components of chief complaint, history of present illness, and past family and social history. Part II will finish the history portion with discussion of the review of systems and will discuss examination and medical decision-making.

The Review of Systems is a series of questions asked while taking an inventory of the organ systems. There are three levels: problem pertinent, extended, and complete. A problem pertinent review of systems consists of documentation of questions relating to one organ system. For example, a question asking if the patient has trouble with their vision, blurred, double vision, burning, would constitute a review of systems for Eyes. This would be a problem pertinent review of systems.

An extended review consists of documentation of two to nine organ systems. This can be documentation of any of the 14 organ systems; constitutional, eyes, ears, nose and throat, genitourinary, musculoskeletal, integumentary, psychiatric, endocrine, hematologic/lymphatic, allergic/immunologic, neurological, cardiovascular, respiratory, gastrointestinal, etc. For example, questions asking if the patient has any dizziness (neurological), or diarrhea or constipation (gastrointestinal) would be enough documentation for an extended review of systems as there are two systems documented.

A complete review consists of ten or more systems reviewed and documented. The documentation of a complete review of systems would be questions asking if the patient has any dizziness (neurological), or diarrhea or constipation (gastrointestinal), blurred vision (eyes), unusual weight loss or gain (constitutional), cough or wheezing (respiratory), chest pain or shortness of breath (cardiovascular), headache, trouble hearing (ENT), rashes or dry skin (integumentary), excessive thirst (endocrine), and anxiety (psychiatric).

The Review of Systems is the most frequently omitted component in physician documentation of services. This omission may cause levels of service to be downcoded to a lower level. For example, the lowest level of H&P requires the documentation of a detailed history. A detailed history consists of an extended review of systems (two to nine systems.) Documentation of anything less would render the service non-billable.

The extent of the examination portion of the H&P is dependent upon the nature of the problem. A physical examination is a set of standard procedures intended to detect and appraise any significant departure from “normal.” The scope and character of the examination performed on a given patient in a given instance depends on the circumstances. A summer camp physical may take much less time than an examination of the neurological system on a patient with multiple sclerosis. Examinations are performed in the manner that personal experience has shown to be most efficient for the physician.

The rationale of physical examination rests on three basic assumptions: that there is such a thing as normality of bodily structure and function corresponding to a state of health; that departures from this norm of structural and functional integrity consistently result from or correlate with specific abnormal states or diseases; and that systematic examination can detect these abnormalities and appraise them in such a way as to yield an accurate diagnosis. Physicians use the terms “normal” and “negative” interchangeably when documenting histories and physicals. Normal means healthy, sound, intact, natural, unimpaired by disease or injury; while negative implies the lack or absence of something. Although they each have different meanings, both are used when documenting the history and physical.

Currently, there are two different sets of guidelines that can be used to document the examination; the 1995 guidelines and the 1997 guidelines. The 1995 guidelines consist of four levels of examination based on seven body areas and 12 organ systems. For the purposes of documentation, the body areas are: chest (including breasts and axillae); abdomen; back (including spine); neck; genitalia, groin and buttocks; head (including face); and extremities (each one would be an area). The organ systems are: constitutional; eyes; ears, nose, mouth and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; skin; neurological; psychiatric; hematologic, lymphatic and immunologic.

The 1995 guidelines are somewhat subjective in nature, however, the lowest level of H&P examination must meet the detailed examination guidelines. These guidelines for documentation of a detailed examination require an extended examination of the affected body area(s) and other symptomatic or related organ system(s).

The 1997 guidelines consist of documentation of either a general multi-system examination or one of the ten specialty examinations of cardiovascular, ears/nose/throat, eye, genitourinary, neurological, skin, Hematologic/lymphatic/immunologic, psychiatric, and respiratory. The 1997 guidelines require a specific number of bullets that must be documented to meet the requirements of the various levels. For example, to properly document the lowest level of H&P, either a detailed or a comprehensive examination must be documented. At a minimum there must be documentation of a detailed examination. Documentation of a detailed examination under the 1997 guidelines varies as to whether they are for the multi-system examination or a specialty examination. The documentation of a detailed multi-system examination consists of at least two elements identified by a bullet from each of six areas/systems or at least 12 elements identified by a bullet in 2 or more areas/systems. The documentation of a detailed specialty examination consists of at least 12 elements identified by a bullet.

The documentation of a comprehensive multi-system examination consists of examination of all elements identified by a bullet in at least nine organ systems or body areas and documentation at least two elements identified by a bullet from each of the nine areas or systems. Specialty examinations are different from multi-specialty as they contain shaded boxes, which are mandated areas of examination for that specific specialty. The documentation of a comprehensive specialty examination consists of an examination of all elements identified by a bullet, whether in a shaded or un-shaded box. Documentation should include every element in each box with a shaded border and at least one element in each box with an un-shaded border. For the specialties of eye and psychiatric, the examinations should include the performance and documentation of at least nine elements identified by a bullet, whether in a box with a shaded or un-shaded border.

The history and physical of an infant will differ substantially from an older child or even an adult. The entire history on a pediatric patient is obtained from sources other than the patient. Parental factors and facts regarding childbirth find a place in these histories. Physicians will document developmental anomalies and disturbances of nutrition, growth and maturation that are not diagnostic considerations in later life. The documentation of a pediatric history should contain the identity of historian(s), their relationship to the patient, and any emotional or other factors that may affect the accuracy of the information that they are providing. The chief complaint and history of present illness are stated from the view of the historian. The past history begins before the birth of the child with a health history of the parents and their families relating to hereditary diseases or abnormalities. The mother’s course of pregnancy, social history relating to tobacco, alcohol caffeine and drug use should be documented. The nutritional history (bottle vs. breast feeding, weight gains etc.) is reviewed. An important component of the history portion is an account of the child’s growth and development. Psychomotor development is traced using “milestones”such as head control, speech, walking and toilet training.

The examination of a small child requires patience and skill. Examination techniques are limited to those requiring no cooperation from the patient. Evidence of congenital or developmental abnormalities identified through the examination should be documented. The neurological examination differs from that of an adult patient. Reflexes present in a normal infant are startle, grasp, rooting and tonic neck reflexes. These reflexes are not found in older children or adults.

The scope and nature of the history and physical depend on several variables. The patient’s complaints give direction to both the history and physical examination and the specialty of the physician will determine the type and extent of diagnostic maneuvers utilized. The documentation of a history and physical should contain more negatives than positives. This is because the physician is not concerned merely with compiling a list of abnormalities, but rather taking a snapshot of the “complete” patient.

Payment for a history and physical rests on consistent and well-targeted documentation and on acquiring the skills to produce it. The physician’s knowledge and ability to document a history and physical will directly determine successful reimbursement for services rendered.

Alice Anne Andress, CCS-P, CCP is the Director of Physician Services at Parente Randolph, LLC.