Billable elements

Low complexity 1 of 8 billable elements, clarify w dr. if not

highest complexity
High complexity 4 of 8 billable elements

1a ONSET: WHEN THE CC BEGIN? how the chief complaint

began (in terms of time)
examples: abrupt, sudden, gradual, etc
additional modifiers to onset (syncope, exertional chest
pain/trauma)

1. Activity at onset: patients’ activity at onset of symptoms

2. Location at onset: Patients location at onset of symptoms

1b. Timing: Kung gaano kadalas mang yari yung chief complaint
- eg constant and worsening

examples: constant (lagi lagi), intermittent (happening here and

there), episodic (nabibilang kung ilang beses nangyari), waxing
and waning (nawawala bumabalik high and lows), progressively
worsening, improving, spontaneously resolving (gumaling na
walang ginawa or ininom ginamot) etc.

2.Duration: HOW LONG HAS THE CC BEEN GOING FOR? Kung

gaano katagal na naramdaman ni patient yung chief complaint.

ex. hours, days, weeks, months, years, since 1984, since

childhood etc.
1. Do not document days of the week (mon, tues) kasi
constantly changing be specific.
2. Counting days. Consider each day as 24 hrs
ex. nag kasakit si px sunday so it counts as day 1, day 2 monday,
day 3 tuesday

if it’s under 3 days/ 72 hours. preffered na give actual hours if

beyond that pwede na icount as days.

3a. Location: WHEN IS THE CC LOCATED? Detailed description

kung san naramdaman yung chief complaint ni px
example if the chief complaint is “ankle pain” kailangan ng
specific location kung saan
anteriorly (Front)? posteriorly (Back)? medially (papunta sa
middle) or laterally (papunta sa side)
location can also help determine the “etiology” (cause or san
nagmula yung chief complaint)

3b Radiation: Movement of a sensation/pain from the origin

ex: ankle pain tas radiating w foot (pwede ksi malapit sya sa
pain origin)
left ankle pain right shoulder pain (2 sepatate pains kasi medyo
malayo na sa origin na pinag mukulan nung sakit.)

Make sure when using radiation kailangan interrelated as

mention as example above

4. Character/ nature: Subjective kung paano dinedescribe ni px

yung sakit na nadama niya

EXAMPLE: throbbing, aching, cramping,sharp, dull, stabbing,

squeezing, pressure "parang inaapakan ng kapre sa dibdib"

Document these cases with quotations (Pag di masyado

naguguide ni dr. or di maexplain ni patient yung sakit properly)
eg “it feels like i am being stabbed with 1000 swords”
(quatations are important)

5a Intensity: Subjective description of pain on a graded scale

comparing mild, moderate, or severe.
DO NOT “GRADE” The patient’s pain for them
e.g., do not describe the symptom as “mild” unless sabihin ni px

5b Severity: Subjective description of pain on a numeral scale

pain is rated on a scale of 1-10 (1 di masakit and 10
pinakamasakit)

Sometimes pain will be rated more than once (e.g. before/ after
bigyan ng gamot)
Need idocument ang fluctuation ng pain and the associated
event with the fluctuation.
ex. 8/10 yung sakit pero pag kainom ng gamot naging 4/10.
kailangan inote both before and after treatment.

6. Associated symptoms: All Symptoms that are NOT the chief

complaints itself
1. Any symptoms accompanied chief complaint
ex. px nag rereklamo about chest pain ay tatanungin kung
meron bang nararanasan na dyspnea(shortness of breath)
diaphoresis(sweating) or nausea. Sakit na di related sa unang
chief compalint.

7 Context: Any circumstance surrounding the onset(nagsimula)

of symptoms

ex: Anong ginagwa ni px, nasang kugar siya, naexpose ba siya sa

sakit etc.

ex. may history na ng migraine

ex. never been rave before tapos syempre maingay yung lugar
dun nag simuka yung sakit ng ulo

8a Modifying Factors/ Alleviating and Aggravating factors:

anything that makes symptoms better or worse
A provider may leave the question open ended:
ex. Does anything improve or worsen the pain/ symptoms m???
Otherwise modifying factors are associated with certain
complaints
ex. Does eating worsen your pain? (could be a gallbladder
problem)

8b Treatment before arrival/: Ginawa ni patient para ma

alleviate yung pain/symptoms

ex. gamot(prescribed or not), OTC medicine, nilagyan yelo, heat,

pressure or bandages, alternative medicines(eg acupunture)
etc.
Did this measure provide any relief benefit
Example: Full relief, partial relief, transient, temporary
without relief

BILLABLE ELEMENTS PRACTICE

Documentation template has been created for a faster and
more accurate charting

to use template properly you must!

1. Place billable element in the proper section
2. Delete any billable element that were not discussed
BILLABLE ELEMENTS PRACTICE
Example: The patient is a 25 year old male who present with
back pain. The patient states that two days ago he was weight
lifting and began to experience a sudden onset of constant
sharp lower back pain that radiates into the right lower
extremity. Since the onset the pain has been gradually
worsening, and he correlates an aggravation of pain with rapid
positional moments. He has since developed intermittent right
leg paresthesias. No associated urinary or bowel incontinence
or muscle weakness. No prior history of back problems or
similar episodes of pain. The patient has taken Tylenol and
Vicodin (the latter from a previous tooth extraction) without
benefit.

Next, "fill-out" the billable elements template:

Onset: Sudden/ Timing: Constant

Location of patient at onset:
Activity of the patient at onset: Weight lifting
Duration: Two days
Location: Lower back/ Radiation: Right leg
Character/ Quality: Sharp
Intensity/ Severity:
Associated Symptoms: Intermittent right leg paresthesias
Context: Weight lifting
Modifying factors: Pain aggravated by certain rapid positional
movement/ Tx before arrival: Tylenol and Vicodin without
benefit

Finally, remove the elements that were not discussed

Onset: Sudden/ Timing: Constant

Activity of the patient at onset: Weight lifting
Duration: Two days
Location: Lower back/ Radiation: Right leg
Character/ Quality: Sharp
Associated Symptoms: Intermittent right leg paresthesias
Modifying factors: Pain aggravated by certain rapid positional
movement/ Tx before arrival: Tylenol and Vicodin without
benefit
Review of systems (SUBJECTIVE - EVERYTHING FROM THE
PATIENT)- Everything in hpi, billable elements must be
matching.
- Systematic listing of all symptoms, organized by system, that
may or may not be associated with the chief complaint.
- symptoms are considered as either "present" or "absent"
"Present" symptoms are designated as "positive" or "+" or
"affirms"
Negative sysmptoms are designated as "negative" or "-" or
"denies"

The provider may ask " are there any other symptoms? or
something to this effect?
TENDERNESS – OBJECTIVE (FROM THE DR)
PAIN- (SUBJECTIVE PX)

Make sure there is no contradicting statements, ROS HPI AND

TEMPLATE
nonproductive cough - walang lumalabas
productive cough - May lumalabas na plema example yellow,
green w/ blood

ED E/M (Evaluation and Management) Codes: The ROS can be

billed at five different levels, depending on the number of
systems present:

99281 Straightforward
99282 Low Complexity - 1 system in ROS
99283 Moderate complexity - 1 system in ROS
99284 Moderate complexity(but more urgent) 2-9 systems in
ROS
99285 High complexity - 10 systems in ROS

To ensure that the chart can be be biled at the highest level(if

your provider wishes)
if a patient is triages as a lever 4-5 ESI: 2-9 systems in ROS
 if a patient is triages as a lever 1-3 ESI: 10 systems in ROS

ESI meaning (LEVEL 1-5)

Level 5- Least complicated, ex. small injury stubbed toe
Level 1- Critical care, traumatic case

4-5- ER (Mid levels/ Advance care provider) Advance care

provider, nurse practioner
1-3 mostly seen for scribers

Using the review of system template

Tanggalin ang di kailangan at idagdag ang kailangan ilagay,
wag maglalagay ng contradicting statements

History given by: ***

History limited by:***
@RFV@

HPI
@NAME @AGE @SEX who present in bed *** with ***

Specialists: Dr. (Name) (Specialty), Dr. (Name) (Specialty)

Billable Elements
Onset***/ Timing***
Location of the patient at onset:***
Activity of patient at onset: ***
Duration:***
Location:***/Radiation:***
Character/Quality:***
Intensity:***/Severity:***
Associated Symptoms:***
Context:(What the patient was doing, where the patient was at,
what the patient was exposed to)
Modifying factors:***/Tx(treatment) before arrival

Constitutional
Eye
HENT(Head, Eye, Nose, Throat)
Resp
Cardio(heart)
GI(gastrointestinal stomach and intestines):
GU(genital and urinary organs)
Muscuskeletal/Extremities(bones, ligaments, tendons, and
cartilage muscles)
Neuro (Brain)
Skin:

ROS examples

Constitutional(pangkalahatang katawan): NEGATIVE No fever,

chills or recent illness POSITVE Positive non restorative sleep
and fatigue
Eye: No visual changes
HENT(Head, Eye, Nose, Throat): NEGATIVE No earache or sore
throat POSITIVE positive sore throat
Resp(involved in breathing) : NEGATIVE No SOB(Shortness of
breath) POSITIVE Positive non productive cough
Cardio: NEGATIVE No chest pain or palpitations.
GI(gastrointestinal stomach and intestines): NEGATIVE no
abdominal pain, nausea, vomiting, constipation or diarrhea.
POSITIVE positive abdominal pain, nausea, vomiting,
hematochezia(bloody stools). No hematemiz(Vomiting blood)
GU(genital and urinary organs): Negative No dysuria(painful
urination), No hematuria(dugo sa ihi) or flank pain( sakit sa
tagiliran)
Musculoskeletal/ Extremities (bones, ligaments, tendons, and
cartilage muscles) : No leg pain or swelling, no back pain
Neuro: No head aches
Skin: No rash

Example: A 42 year old male presents to the ER with abdominal

pain. During the initial encounter the patient also reported
having nausea and vomiting, and one bowel movement in
which he had bright red bloody stools. Otherwise, he denied
blood in his vomitus, diarrhea, painful urination or blood with
urination, kidney pain, feverr, or chills. He also did not have any
changes in vision, shortness of breath, chest pain, palpitation,
leg pain or swelling, headaches or other symptoms. However, as
the physician was leaving the patient did mention that
yesterday he had a sore throat and a nonproductive cough
which kept him from sleeping, resulting in non-restorative sleep
and fatigue.
Example: A 42 year old male presents to the ER with abdominal
pain. During the initial encounter the patient also reported
having nausea and vomiting, and one bowel movement in
which he had bright red bloody stools. Otherwise, he denied
blood in his vomitus, diarrhea, painful urination or blood with
urination, kidney pain, fever, or chills. He also did not have any
changes in vision, shortness of breath, chest pain, palpitation,
leg pain or swelling, headaches or other symptoms. However,
as the physician was leaving the patient did mention that
yesterday he had a sore throat and a nonproductive cough
which kept him from sleeping, resulting in non-restorative
sleep and fatigue.

Document symptoms under the correct system in the template

as "positives" or "negatives"

Constitutional: No fever, chills or recent illness. Positive non

restorative sleep and fatigue.
Eye: No visual changes
HENT: No earache or sore throat. Positive sore throat.
Resp: No SOB or cough. Positive nonproductive cough.
Cardio: No chest pain or palpitations.
GI: No abdominal pain, nausea, vomiting, constipation or
diarrhea. Positive abdominal pain, nausea, vomiting,
hematochezia. No hematemesis.
GU: No dysuria, urgency or frequency. No hematuria or flank
pain.
Muscuskeletal/ Extremeties: No leg pain or swelling. No back
pain.
Neuro: No headaches

FINAL ANSWER
Constitutional: No fever, chills or recent illness. Positive non
restorative sleep and fatigue.
Eye: No visual changes
HENT: No earache or sore throat. Positive sore throat.
Resp: No SOB or cough. Positive nonproductive cough.
Cardio: No chest pain or palpitations.
GI: No abdominal pain, nausea, vomiting, constipation or
diarrhea. Positive abdominal pain, nausea, vomiting,
hematochezia. No hematemesis.
GU: No dysuria, urgency or frequency. No hematuria or flank
pain.
Muscuskeletal/ Extremeties: No leg pain or swelling. No back
pain.
Neuro: No headaches
Skin: No rash