ED Coding and Reimbursement Alert

Question: I am having trouble deciding between E/M levels for this encounter: The notes clearly indicate that the ED physician performs comprehensive examination and high-complexity medical decision making for a patient with a possible myocardial infarction (MI) who had suffered an MI five years earlier; the physician's final diagnosis is Dressler's syndrome. I am not sure if the history level is comprehensive or detailed. The physician addressed five history of present illness (HPI) elements and reviewed 10 systems (ROS). Is this a level-five E/M? Indiana Subscriber Answer: You'll have to review the notes to determine the level of past, family, and social history (PFSH) before deciding on an E/M code. This encounter involved extended HPI and a complete ROS, both requirements for a comprehensive ED E/M. A comprehensive history also requires a complete PFSH,which you do not mention in your description. During a complete PFSH, the physician asks the patient [...]