The best 99214

Hey everyone, today I'm continuing with part 2 of our series on writing the best 99214 note that you can. So what is a great 99214 note? From our first newsletter, I define it as:

1. Do only the amount of History and Physical Exam that you think is necessary and important for that particular patient.
2. Write the note and consciously put in all the requirements of a 99214 note.
3. Go over and above and satisfy all 3 things of History, Exam, and Decision Making (not just 2/3).

Today we're going to cover ensuring that an adequate History is documented. There are 4 parts to History. For a Detailed History, you need a Chief Complaint (CC), 4 elements of History of Present Illness (HPI), 2 elements of Review of Systems (ROS), and at least 1 element of Medical Decision Making (MDM). Let's tackle these in order.

Chief Complaint

According to CMS, it is acceptable to include the CC as part of the HPI. However, I've been hearing rumors about some RAC audits where if there was not a specific CC section, then they were not given credit for it. And guess what? If you don't have a CC, then you cannot satisfy any level of history since all 4 elements of History must be done.

So state the Chief Complaint clearly!

But what if the chief complaint has nothing to do with why they're here? What if they tell the nurse they are here for a 'check-up' but in reality they are here for management of 7 chronic diseases? That is easy. Remember, the chief complaint is the 'reason for the patient's visit, usually stated in the patient's own words.' The chief complaint is defined as the reason for the patient's visit. It is not why the patient states they are here. Make sure you are clear about this! This is your note that you are signing off on. No matter what the patient tells you or the nurse, and no matter what the nurse writes as the Chief Complaint, you must put the real Chief Complaint in the note before you sign your name to it.

History of Present Illness

The HPI is composed of 8 elements. I know you feel that you know this from medical school, but here's a quick recap:

1. Location
2. Quality
3. Severity
4. Duration
5. Timing
6. Context
7. Modifying Factors
8. Associated Signs and Symptoms

To qualify for a Detailed History, you must have at least 4 elements of HPI. Here's what I recommend. When you first start writing your note, make sure you list 4 elements in the first 2-4 sentences, then write anything else you think is important for the care of the patient. If you cannot come up with at least 4 elements, then that is fine. You write what you have but keep in mind you may not have enough data for a 99214 note. And that's okay! You do not go back in and ask the patient more questions. That is doing an 'unnecessary medical procedure' on a patient and actually borders on fraud!

But most of the time you will have done at least 4 elements even without thinking about it. Here's what I recommend for patients with acute problems: Location is the affected system. No problem. You've probably asked how long they've had this complaint (duration). You might have asked how bad it is. You might have asked when it happens (timing or context). You probably asked if they've taken any meds or tried anything (modifying factors). You might've asked if anything else is going on with it.

I typically phrase the first 3 lines like this: Patient is here for complaints of (duration) of (location). State associated symptoms. State modifying factors.

Here are some examples:

1. Here for 3 days of subjective fever. Lots of coughing. OTC meds haven't helped. (this actually has 5 elements because 'subjective' can be counted for quality or severity).
2. Here with several months of intermittent constipation. Occasionally has bright red blood in stool. Drinks lots of calories and has poor diet. (Also 5 because intermittent is timing).
3. Here with a few weeks of mild URI symptoms. Hasn't tried any meds. (few weeks=duration, mild=severity, location=ENT or respiratory system, and has the meds are the modifying factor).

You see how easy this is? Just make sure your first sentences cover at least 4 elements. Then write whatever HPI is appropriate and you never have to worry about that part of coding anymore!