427Pillar 1a: All Notes Require a Chief Complaint
Pillar 1b: HPI (History of Present Illness)
Most HPIs are rarely inadequate for billing. To bill maximally (or level 5), one
has to have at least four bullets under the HPI. The bullets to choose from include
location, quality, severity, timing, duration, context, modifying factors, and associ-
ated signs and symptoms. Keep in mind that location is sometimes a freebie; for
example, erectile dysfunction is typically located in the penis, but this does not need
to be explicitly stated. Thus HPIs can be relatively brief from a billing standpoint.
However, you may want to include more bullets if it improves patient care.
Pillar 1c: ROS (Review of Systems)
The most common error performed by MDs is an insufficient ROS. A weak ROS
instantly drops a level 5 visit to level 2 or 3!!! This is because the lowest billable
section of the history is what determines what one can charge. For example, the bill-
ing level from a history with a CC, a seven-item HPI, and a complete past medical
family and social history (PMFShx) but a poor ROS takes the history section down
to level 1 or 2. When submitting the final bill, one can only charge the lowest charge
section from history, PE, and MDM – no matter how good a physical exam you
performed or how complex your decision was, the note is doomed to level 1 or 2.
At level 5, ROS requires ten systems with one bullet each. Again for patient care
you may wish to include more bullets in specific sections. The ROS list to choose
from includes constitutional, eyes, ENTM, respiratory, GI, GU, musculoskeletal,
integument, endocrine, CV, heme/lymph, allergy/immunity, neurologic, and psy-
chologic. Do not make the mistake of stating ROS per HPI or “all systems negative.”
This is inadequate. It is easiest (and most bulletproof) to simply list ten systems with
one bullet each. Alternatively, you can “update” someone else’s complete ROS if
you document who wrote it and when and if this note is retrievable in the electronic
medical record. This seems like more work to me than just listing ten systems.
Another alternative particularly in clinic is using a scanned form that the patient fills
out – this again needs to be retrievable from the record and requires your signature
and date verifying you indeed reviewed it. In this case, the ROS can look like ROS
reviewed from the scanned patient clinic form, pertinent positive include x, y, and z.
You may have noticed that this section came before the PMFShx. This is on pur-
pose; it is way more important. A good doctor thinks about how each body system
relates to the chief complaint.
Pillar 1d: PMFShx (Past Medical, Family, and Social History)
The highest level note for billing requires only one bullet each from these three
sections. Thus, this section can be very brief. No need to list 40 medications, 17
medical problems, etc. unless you think they are relevant to the CC or to optimize
patient care.
Take another look at Fig. 23.2, and you can easily see how this works. As an
example, an E3 history section requires a CC, one HPI bullet, and one pertinent
ROS bullet. Peruse the N3/C3 requirement: CC, four HPI bullets, two ROS bul-
lets, and one of the three PMFShx bullets. Finally check out the C4/N4
23 Evaluation and Management Documentation, Billing, and Coding