Aside from clearly documenting the chief complaint or reason for the encounter to establish medical necessity for your service, certain history, exam and medical decision making elements in the admission note are required to support your billing.
Level 2 (moderate complexity) and 3 (high complexity) initial hospital care have the same comprehensive history and exam requirements. If a required history or exam element is lacking, the documentation would support a level 1 (low complexity) service. If you are attesting to an admission note by housestaff, make sure these elements are covered in either of your notes.
A. HISTORY
Comprehensive history requires:
• Chief complaint
• An extended history of present illness
• Complete (10 or more elements) review of systems
• Past medical, family and social history
Note: Phrases such as ‘family history deferred/unknown’, ‘review of systems as per HPI’ or ‘ROS negative’ are not acceptable substitutes.
B. EXAM
Comprehensive physical exam requires a minimum 8 of 12 organ systems listed below:
o Constitutional
o Eyes
o Ears, nose, mouth and throat
o Cardiovascular
o Respiratory
o Gastrointestinal
o Genitourinary
o Musculoskeletal
o Skin
o Neurological
o Psychological
o Lymphatic/hematologic/immunologic
Note: Body areas such as head, neck or extremities do not qualify as an “organ system”.
C. MEDICAL DECISION MAKING
Requires assessment, clinical impression or diagnosis and the plan for each problem managed.
Contributed by Jodie Medeiros CPC, COC, ICDCT-CM, Compliance Analyst & Educator, Mass General Hospital, Boston, MA
