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Chiropractic News

May 2008

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Practical Documentation: Patient history sets the tone and turns up the volume

Doctors of chiropractic are among a small group of providers authorized to use the evaluation and management (E/M) code set.

Chiropractors use the chiropractic manipulative treatment codes (CMT) for routine visits. These include a component of E/M in the value.

The E/M code set is perhaps one of the most underused in the profession. There are many times when it’s most appropriate to use an E/M code in addition to a CMT code in patient encounters, such as new patient visits, re-evaluations to determine if a change in treatment plan is necessary, new injuries, reinjuries, exacerbations, and others.

Documentation is key to show the medical necessity of using these codes. One of the most important components to E/M coding and documentation is history.

The initial history taken from a new or returning patient sets the tone for the entire case. This is not the time to skimp on details, paperwork, or your evaluation.

Information obtained in the history guides and directs you in understanding the needs of your patient; it also helps direct the treatment plan.

Let’s explore the documentation requirements for the history section of the E/M code set, and unravel the pieces of the puzzle to ensure you are gathering all you need to establish medical necessity for your care.


The E/M documentation requirements dictate four components of history:

• Chief complaint (CC);

• History of present illness (HPI);

• Review of systems (ROS); and

• Past, family, and/or social history (PFSH).

A staff member can gather this information from the patient, or the patient can complete this information on a history form. Regardless of the method used, you must note you have reviewed the information.

Here are some guidelines for documenting each of the four components of a patient’s history:

• Chief complaint (CC). The CC is a concise statement that describes the symptom, problem, condition, diagnosis, doctor’s recommended return, or other factor that provides the reason for the visit, usually in the patient’s own words.

The patient’s record should clearly reflect the CC or multiple complaints, if they exist. Note that all levels of history include a CC.

• History of present illness (HPI). This is a description of the chronological development of the patient’s present illness from the first sign and/or symptom, or from the previous visit to the present one.

It could include one or more of the following elements: Location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms.

The more detail you use in establishing history, the more thorough your record will be. This could go a long way toward establishing medical necessity for your treatment.

Coding requirements vary depending on the level of history provided. Be sure to review the E/M coding guidelines for exact requirements.

• Review of systems (ROS). The ROS is an inventory of body systems

you obtain by questioning the patient.

Use it to identify signs and/or symptoms the patient has or has had in the past.

This is one area easily documented with a good intake form that includes all of the conditions a patient may have had in the past or has presently. A check sheet is a great way to accomplish this.

Some of the systems that require review include: Constitutional symptoms (such as fever or weight loss); eyes, ears, nose, mouth, and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; and neurological symptoms.

For coding purposes, the number of systems reviewed helps determine which level of history you provided.

This is where the lack of documentation can easily foil your best intentions when coding E/M services.

Be sure to review the full E/M documentation guidelines to gain a thorough understanding of these requirements.

• Past, family, and/or social history (PFSH). This is exactly what it sounds like. It consists of a review of past history (the patient’s past experiences with illnesses, operations, injuries, and treatments); family history (a review of medical events in the patient’s family, including conditions which may be hereditary or place the patient at risk); and social history (an age-appropriate review of past and current activities).

This information can go a long way toward helping you with your diagnosis and treatment plan.

For example: If a patient lists bowling three times a week as a favorite social activity, it’s important to know if you must restrict their activities.

You can gather most of this information through excellent intake paperwork and procedures.

For new patients, once you obtain the history, your consultation will help determine the medical necessity for the treatment. Review the history forms, note all positives and pertinent negatives, and elaborate on anything you find.

Don’t forget that when performing E/M services on established patients, the same rules apply. Be just as detailed in the history, exam, and clinical decision-making when you perform re-evaluations.

Patient history is the golden nugget of E/M documentation. It’s some of the easiest information to gather and can be accomplished with minimal effect on office infrastructure and efficiency.

Correctly gathered, fully completed, and totally analyzed patient history can be a tremendous tool in justifying and meeting all the medical-necessity requirements for your chiropractic care.

Kathy Mills Chang is the founder of her own consulting firm and assists doctors with finding financial and reimbursement ease in practice and helping them to make and keep more money. She also serves as Foot Levelers’ insurance advisor. She can be reached at or through her Web site,

Documentation needs to be done by the rules to get reimbursed. See “Play by the rules” at

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