History Taking:History Taking:What is His Story?

Jane T Shuman, COT, COE, OCS

What is His Story?Jane T. Shuman, COT, COE, OCSPresident

OBJECTIVESOBJECTIVESOBJECTIVESOBJECTIVES• Define Chief Complaint and History of Present

Illness• Identify frequently presenting symptoms• Discuss conditions related to above• Discuss conditions related to above• Name the eight quantifiers and provide examples of

each• Suggest probing questions that tie the symptoms to

possible diagnoses

WHY IS IT NECESSARY?WHY IS IT NECESSARY?WHY IS IT NECESSARY?WHY IS IT NECESSARY?ComplianceRevenueChart audits

History plays pivotal role, particularly with y p y p , p yEvaluation and Management codesLess documentation required with eye codesUncertain which will be coded at onsetUncertain which will be coded at onset.

MEDICAL vs. VISIONMEDICAL vs. VISIONMEDICAL vs. VISIONMEDICAL vs. VISIONVISION MEDICALVISION

Not all carriers support this

MEDICAL

Needs a symptom or medical reason for visitthis

HMOs, Carve outsNOT MEDICARE

medical reason for visitCC/HPI

Refractive history does Patients often unawareLower copaymentsNo associated tests

not applyMedicare and othersTests billable same dayNo associated tests y

DOCUMENTATIONDOCUMENTATIONDOCUMENTATIONDOCUMENTATION• Chart is a legal document• History sets the tone for visit• Must reflect conversation from patient’s

perspective (“ ”)perspective ( … )• Negative responses to probing questions• “If it wasn’t documented, it wasn’t done”

ElectronicElectronic MedicalMedical RecordRecordElectronicElectronic MedicalMedical RecordRecord• GIGO

• Patient presents for 1 year cataract follow up. No vision changes. No flashes or floaters. Denies pain. Bothered by the headlights of oncoming cars.y g g

• Diabetic eye exam. No visual complaints. BS “good”. Uses artificial tears

• Red eye. Was in Red eye. Was in

BE ALL EARSBE ALL EARSBE ALL EARSBE ALL EARS• Listen carefully before writing anything• Medical necessity does not include

• No problems• Annual exam• Annual exam• Need stronger glasses• Lost my glasses• The doctor likes to see me once a year• I got a postcard……….

2 sets of codes2 sets of codes2 sets of codes2 sets of codesEye Codes (92…) Evaluation

/Management Codes• Intermediate or

Comprehensive

/Management Codes (99…)

• Used by all of Comprehensive• Fewer documentation

requirements

ymedicine

• Strict billing guidelines• Higher revenue guidelines• Defined CC/HPI• Specific Exam

components• Medical Decision

Making

UNKNOWN OUTCOMEUNKNOWN OUTCOMEUNKNOWN OUTCOMEUNKNOWN OUTCOME• At work up, the procedure code is unknown.• Therefore:

• Assume E/M code will be billed• Follow CC/HPI guidelines for higher level codes• Follow CC/HPI guidelines for higher level codes

COMPONENTSCOMPONENTSCOMPONENTSCOMPONENTS

Chief Complaint (CC)History of Present Illness (HPI)R i f S t (ROS)Review of Systems (ROS)Past, Family and Social History (PFSH)

CHIEFCHIEF COMPLAINT:COMPLAINT:The reason the patient is in the chairThe reason the patient is in the chair

1. Return follow up2. New Problem3. Routine Care4. ConsultCo su t

Return Follow UpReturn Follow UpReturn Follow UpReturn Follow Up•The most likely scenario•The physician asked the patient to return•Check the previous note (plan) before

documenting anything; carry over in EMRP id i i h di l d• Provides consistency in the medical record

•Any time span4 h F/U OAG• 4 month F/U OAG

• 1 year F/U cataract OD>OSD th d t t h?Do the dates match?

New ProblemNew ProblemNew ProblemNew Problem• Self/physician referred

• For example: Red Eye• Consult

• “Evaluation of Such and Such requested by Dr So and• Evaluation of Such and Such requested by Dr. So and So”

• Consult codes eliminated 2010Gl bl h ld b d d i t f• Glasses problems should be worded in terms of vision – Medical exam• “Blurred vision at distance” instead of “Needs

stronger glasses”

• HISTORY OF PRESENT ILLNESS• The story behind the condition or chief complaint• Expressed by using Quantifiers

• Negative responses must be documentedNegative responses must be documented• 1 – 3 quantifiers constitutes Brief history• 4 or more quantifiers constitute Extended history

• Important for E/M codes• Important for E/M codes

JOURNALISMJOURNALISMJOURNALISMJOURNALISM• Think of the

quantifiers as the

But they must relate to the Chief ComplaintComplaint

• LOCATION • SEVERITY• Where is the problem?

• DURATION• How long has it been

• How mild or bad?• QUALITY

• Describe the symptomHow long has it been going on?

• TIMING• When during the day

d i ?

Describe the symptom• MODIFYING FACTORS

• What makes it better or worse?

does it occur?• CONTEXT

• With what activity does it present itself?

• ASSOCIATED SIGNS & SYMPTOMS• What else occurs?

present itself?

4 = $4 = $4 $4 $• In the event this is a medically complex visit, 4

quantifiers will allow the physician to bill the highest level of service applicable.

• WEAK HISTORIES PREVENT STRONG BILLING!!

LOCATIONLOCATION DURATION DURATION Where?Where? How long?How long?

LOCATIONDURATION

TIMING CONTEXT SEVERITY QUALITY MODIFYING

FACTORS ASSOCIATED

SIGNS & (when) (what activity) (mild-bad) (description)

FACTORS (better or worse)

SYMPTOMS (what else)

Be Curious

What is the Review of What is the Review of S t ?S t ?Systems?Systems?

• A screening device to uncover potentially• A screening device to uncover potentially significant symptoms not otherwise elicited.

• Symptoms related to the HPIy p• Other active problems• Determine the pertinent positives and

i hi h ill id i ki di inegatives which will aid in making a diagnosis• A series of questions going from “head to toe”

ROS= Review of SystemsROS= Review of SystemsROS Review of SystemsROS Review of Systems• Relates to the condition of the rest of the body• Idea is that bodily systems are inter-related and

eyes may be affected by conditions elsewhere• The review of systems (or symptoms) is a list of• The review of systems (or symptoms) is a list of

questions, arranged by organ system, designed to uncover dysfunction and disease. A l ROS k SYMPTOM l d i• A complete ROS asks SYMPTOM related questions

• Do not ask “ Do you have any cardiovascular problems?”p

HPIHPI vs ROSROSHPI HPI vs ROS ROS

History of Present Illness Review of SystemsHistory of Present Illness HPI is typically

what is provided in the patient's own

Review of Systems ROS is an inventory

of systems where th id kthe patient s own

words or in response to questions

the provider asks questions of the patient regarding

ibl t Arrange HPI as

they relate to multiple chief

possible symptoms by system. ROS is a verbal

multiple chief complaints. system inventory

ROSROSROSROS• The 14 systems:

o Constitutional – fever, weight loss/gain, fatigue, etco Ear/Nose/Throat – hearing loss sinus problems soreo Ear/Nose/Throat hearing loss, sinus problems, sore

throato Cardiovascular – high blood pressure, heart problems, etco Endocrine – diabetes, thyroid problems, grave’s disease

H l i l/L h i AIDS HIV h i i hi ho Hematological/Lymphatic – AIDS, HIV, hepatitis, high cholesterol

o Respiratory – asthma, emphysema, bronchitis, TB, COPDo Genitourinary –genital, kidney, bladder problemso Genitourinary genital, kidney, bladder problemso Gastrointestinal – heartburn, reflux, GERD, abdominal paino Integumentary – rashes, rosacea, dry skin, breast problemso Musculoskeletal - arthritis, lupus, gout, osteoporosis

l l h d h k lo Neurological – headaches, stroke, MS, paralysiso Psychiatric – depression, anxietyo Allergic/Immunologic – seasonal allergies, hay fevero Eyes – glasses contact lenses eye disease eye injurieso Eyes – glasses, contact lenses, eye disease, eye injuries,

eye surgeries

REVIEW OF SYSTEMSREVIEW OF SYSTEMS

A h h d f i h i fAnother method of capturing the review of systems is while recording the medications. It stands to reason that if a patient is taking a prescription medication he/she has a conditionprescription medication, he/she has a condition which is being treated. Therefore, when capturing the medications, ask why it has been prescribed and note the condition next to theprescribed and note the condition next to the appropriate system. At the end of the medication portion of the history, you may find you have satisfied a large portion of the review f l i l f l fof systems, leaving only a few systems left to

investigate.

CLASSIFICATIONS FOR VISITCLASSIFICATIONS FOR VISIT

CATEGORIES of FREQUENTLY CATEGORIES of FREQUENTLY PRESENTING SYMPTOMS for NEW PRESENTING SYMPTOMS for NEW COMPLAINTCOMPLAINT

• Blurred Vision• Refractive Error

• Eye Pain• Foreign Body

• Cataract• Angle Closure

g y• Trauma• Elevated IOP

• Optic Neuritis• Papilledema

• Corneal Abrasion/Erosion

CATEGORIES of FREQUENTLY CATEGORIES of FREQUENTLY PRESENTING SYMPTOMS for NEW PRESENTING SYMPTOMS for NEW COMPLAINTCOMPLAINT• Flashes and/or

FloatersDIRT

• D – Dryness• Ophthalmic Migraine• PVD

R ti l h l t

• I – Itching• R – Red

• Retinal hole or tear• Retinal detachment• Diabetic retinopathy

• T – Tearing• Diabetic retinopathy

Dry Eye Syndrome

CONDITIONS AND RELATEDCONDITIONS AND RELATED QUESTIONS

• CATARACT• Blurred Vision

• Distance or NearSensitivity to Glare• Sensitivity to Glare• Oncoming Headlights

• Lifestyle Issuesy• Driving• Reading• Golf• Golf

CATARACT: Questions to AskCATARACT: Questions to AskQQ

• Impairment to • Second eyeActivities of Daily Living (ADL) justify surgery

• If need for surgery is determined prior to first eye cannot billsurgery

• Difficulty Driving?• Difficulty Reading?

first eye, cannot billTHEREFORE…

• ADL must be• Difficulty Reading?• Photoadaptation?• Falling?

ADL must be documented again• Photophobiag

• Trouble following golf ball?

• Fusion• Anisemetropia

CATARACTCATARACTCATARACTCATARACTHis Story:• CC: 1 year return cataract OD>OS • HPI: Bothered by oncoming headlights when driving

at nightat night

MACULAR• MACULAR DEGENERATION• Wavy lines• Wavy lines• Distortion• Yellow line in road

AMD: Questions to AskAMD: Questions to AskAMD: Questions to AskAMD: Questions to Ask• Faces blurred?

• Hallway approach• Grandchildren

• Difficulty reading?• Letters jumping?E bli h d iEstablished patient:

Amsler grid frequencyq y

Amsler changes?

AMDAMDAMDAMD• His Story:• CC: Wavy Lines OS x 2 days• HPI: Pt has difficulty keeping signature on line

when writing checks Using ruler to trackwhen writing checks. Using ruler to track signature helps

• GLAUCOMA• No symptoms• Describe the disease

• Location• DurationDuration• Drop compliance• Side effects

GLAUCOMA: Questions to GLAUCOMA: Questions to A kA kAskAsk

• Frequency of drops• Side effects

• SOB• Fatigue• Red eye

Ch i il• Change in pupil or lashes

• Skin discolorationSkin discoloration• Change in vision

GLAUCOMAGLAUCOMAGLAUCOMAGLAUCOMA

His Story:• CC: 4 month Return for glaucoma OUg• HPI: Forgets bedtime drop frequently; no

vision changes noted

HEADACHE• Location

• Frontal vs. temporal• Duration• Frequency

HEADACHE: Questions to HEADACHE: Questions to A kA kAskAsk• Frontal • H/O Migraines?

• Timing and context• Squinting?

• Triggered by food or alcohol?

N di ti ?• Temporal/brow• Difficulty chewing or

weight loss?

• New medications?• Medication relief?

Y/N?weight loss?• Numbness or

tingling?

• Y/N?• Tylenol, Aspirin…

g g• Pain combing hair?

HEADACHEHEADACHEHEADACHEHEADACHE

His Story:• CC: Evaluation of headache requested

by Dr. Primary Care• HPI: Dull pain over Rt brow X 4 days;

bl fconstant. PMH notable for HTN

DRY EYE DISEASEDRY EYE DISEASEDRY EYE DISEASEDRY EYE DISEASE• Most common • Eyes don’t feel

reason that a patient seeks eye care appointment

right• Heavy feeling

care appointment• Symptoms can be

vague

• Sandy, itchy, burning

vague • Tearing

DRY EYEDRY EYEQ ti t A kQ ti t A k• LocationQuestions to AskQuestions to Ask

• Duration• Auto-immune

di ?disease?• Contact lens wearer?

T l t• Tears, plugs, etc.• Computer use?

Sit under a fan?• Sit under a fan?• Allergies?

DRY EYEDRY EYEDRY EYEDRY EYE

His Story:• CC: OU

uncomfortable X several monthsHPI Vi i bl• HPI: Vision blurs but clears on blink. No H/O /artificial tears or punctal plugs

• Annual Diabetic eye exam with Retinopathy• Location

• How long a diabetic• Duration

DIABETES: Questions to DIABETES: Questions to A kA kAskAsk

• Blood Sugar Level• A1C or Glucose

• Diet and Exercise• Vision Fluctuations

• Correspond to sugar fluctuations?

www.webmed.com

DIABETIC EYE EXAMDIABETIC EYE EXAMDIABETIC EYE EXAMDIABETIC EYE EXAM

His Story:

CC 1• CC: 1 year return for NIDDM diabetic eye exam OUeye exam OU

• HPI: BS stable A1c 6.7. Notes no visual changes; exercises 3 X/wk

• FLASHES & FLOATERS• Which Eye?• How long?• Central or Moving• Constant vs.

I t itt t?Intermittent?• Eyes open or closed?• Scintillating or streaks?• Scintillating or streaks?• Eye trauma?

• LOSS OF CENTRAL VISION

• Which eye?• How long?• Constant or

intermittent?• Black or foggy?• Headache?

• Veil, Cobweb or ,Curtain

• Which eye?• How long?• Flashes/Floaters?• Progression?g• Trauma?

• GRADUAL LOSS OF • SUDDEN LOSS OF VISION• Which eye?

VISION• Which eye?

• How long• Distance or near?

f d

• How long?• Pain?

T l l• Time of day?• Last glasses

prescription?

• Total loss vs. light/motion?

prescription?

• POOR NIGHT VISION• Location?• Duration?

l h f• Family history of night blindness or RP?

• Bothered by glare of oncoming h dli ht ?headlights?

• History of cataract?

VISUAL COMPLAINTSVISUAL COMPLAINTS• Double Vision

VISUAL COMPLAINTSVISUAL COMPLAINTS

• One eye or both• Sudden onset?

A i t d i• Associated signs and symptoms• StrokeStroke

• Face• Arm• Speech• Speech• Time

• Headache

• RED EYE• Location• Duration

h• Light sensitivity?• Pain, tearing,

discharge?discharge?• All over or spot?

• Eye Pain• Location• Duration

h• Vision change?• Throb, ache, dull,

grittygritty• Nausea?• Constant or

intermittent?

• PRESSURE BEHIND • PULLING SENSATIONEYE• Location

D i

• Location• Duration

l ff• Duration• Sinus problems?

• Medications

• Glasses on or off?• Constant vs.

intermittent?• Medications• New glasses Rx?

intermittent?• Double vision?

PEDIATRIC PATIENTSPEDIATRIC PATIENTSPEDIATRIC PATIENTSPEDIATRIC PATIENTSNon VerbalNon-Verbal

• Parent is historianP• Pregnancy

• Fullterm?• Complications?

• Family History• Strabismus• Amblyopia• Congenital Cataract• Retinoblastoma

• PhotographsI h b b i h d ?Is that baby wearing shades?

• BLURRED VISION• Location• Duration• Distance or near?• Do glasses/

squinting help?squinting help?

REFRACTIVE ISSUESREFRACTIVE ISSUESREFRACTIVE ISSUESREFRACTIVE ISSUESNeeds new

glasses becomesBlurred VA at D or

N• Difficulty seeing

t t i h street signs when driving

ConclusionConclusionConclusionConclusion• Obtaining an accurate history is the critical first

step in determining the etiology of a patient's problem

• There is no substitute for being thorough in yourThere is no substitute for being thorough in your efforts to care for patients

• Obtaining an accurate history takes a certain amount of time regardless of your level ofamount of time, regardless of your level of experience or ability.

• In the end it is the cornerstone of good care

Grey’s AnatomyGrey s Anatomy"A patient's history is as important as their symptoms. p y p y pIt's what helps us decide if heart burn's a heart attack... if a headache's a tumor. Sometimes patients will try to re-write their own histories. They'll claim they y y ydon't smoke, or forget to mention certain drugs... which in surgery can be the kiss of death. We can ignore it all we want, but our history eventually always ignore it all we want, but our history eventually always comes back to haunt us.

- Meredith

THANK YOU FOR YOUR ATTENTIONATTENTION

Jane T. Shuman, COT, COE, OCS, , ,617-429-6155 - jshuman@eyetechs.com

eyetechsincy