History and Exam in 2021

Are they really gone?

There were big changes to office and outpatient E/M codes in 2021, and thankfully some of them have given us a new-found sense of relief. When the AMA rewrote the guidelines, they removed the history and exam from the coding equation, but are they really gone? The answer is a bit convoluted; yes, they are no longer used, but no, we cannot ignore them. When it comes to documenting, we need to remind providers that they still influence code selection.

Under the new CPT guidelines, the history and exam have been reduced to “medically appropriate.” In other words, it’s up to the provider to decide what information to collect from the patient and to what level of exam to perform. It’s liberating knowing that we no longer need an overinflated review of systems or an extensive exam just for the purpose of meeting a code’s description! While all of this is good news, both are still a part of coding since they assist coders and auditors in determining the status or seriousness of an illness or injury, and how it impacts the level of medical decision-making. 

The history of the present illness begins the diagnostic process and sets the tone for the visit. When coders and auditors evaluate a progress note, they get a “feel” for the E/M level just by reading the history. Is this an acute visit or a routine follow-up on chronic conditions? If a subsequent visit, is the patient at goal or unstable? How high are the blood sugars or blood pressures at home? For an acute visit, how severe is the pain, and how often is it happening? What are the associated signs and symptoms?

The exam can further define the severity or stability of a complaint or condition when the assessment is missing these important descriptors for calculating the medical decision-making. The exam may illustrate concerning features of a lesion, the degree and surface area of a burn, the characteristics of abnormal heart/lung/bowel sounds, the presence or absence of abdominal tenderness or distension, etc. All of these may factor into determining the level of decision-making under the 2021 changes.

In 2021, CPT revised the calculation of decision-making for office and outpatient E/M codes. One of the changes is related to the number and complexity of problems addressed. Now, the problems are categorized by their nature, starting with self-limited or minor and progressing up to threat to life or bodily function. As the problems progress in complexity, the decision-making increases, as does the code. If the provider omits details in the assessment, coders and reviewers could garner, with a bit of caution, helpful information from the history or exam to categorize a problem more accurately.

If coding based on time, the history and exam may also demonstrate the complexity of the case, and from a medical necessity standpoint, support those encounters that are most time-consuming and coding to higher levels.

Since a well-written, pertinent history and/or exam steers a coder toward an E/M level, it may, at times, assist with coding accuracy. For example, what if a coder has a case where the decision-making calculates lower than expected when compared to the history or exam? It may prompt the coder to double-check their work: “This feels like a level five, did I miss something?”

Taking the importance of the history and exam one step further, when appealing a payer’s medical necessity challenge, excerpts from the history or exam can be used. The appeal writer may find themselves quoting the record “the pain was described as the worst of her life” or “the patient stated that his fever was as high as 104.5 at home,” or “the exam was positive for rebound tenderness” or “the respiratory exam was positive for course crackles.” Again, the history and exam can fill in gaps in a less-than-thorough assessment where medical necessity is usually best illustrated.

The 2021 changes are certainly a step in the right direction, offering providers a sense of relief, but the history and exam are still factored into the coding scenario. And of course, we cannot forget their importance from a medico-legal standpoint. To be successful in coding, auditing, and appeals, we must recognize the contribution of history and exam, encourage providers to adhere to best practices in documentation, and continue to monitor updates from the AMA and the payers.

About the Author

Linda Duckworth has over 30 years’ experience in health care ranging from practice management and revenue cycle analysis to audit and compliance. Linda currently oversees the technical review of work products for abeoAdvisory Solutions and continues to perform audits that are actionable as well as educational.