Gastroenterology Coding Alert

Question: I am having trouble deciding between E/M levels for this encounter: The notes clearly indicate that the gastroenterologist performs comprehensive examination and high-complexity medical decision making for a patient with a diagnosis of Crohn's disease of the small and large intestines. As for history, however, I am not sure if the level is comprehensive or detailed. Notes indicate that the gastroenterologist 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 personal, 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 new patient E/M. A comprehensive history also requires a complete PFSH, which you do not mention in your description. During a complete PFSH, the gastroenterologist asks the patient direct [...]