General Surgery Coding Alert

Question: When coding an E/M chart, how do we know where the “current” conditions/symptoms and the “past” conditions/symptoms fit into the code choice?

Tennessee Subscriber

Answer: The chief complaint (CC), history of present illness (HPI), and review of systems (ROS) parts of an E/M code include notations about any current conditions or symptoms that the patient has. The past, family, and/or social history (PFSH) part of an E/M code describes any conditions the patient has experienced in the past that might be related to the current condition/symptoms.

For instance: If the patient presents for treatment of a feeding tube wound that won’t heal, the wound itself is part of the CC and HPI. If the patient has been diagnosed with Type 2 diabetes, that is part of the PFSH. You can see that the PFSH can provide important information to inform your surgeon about chronic conditions that might impinge on current conditions and treatment options. For an E/M code choice, the level depends in part on these history components. For instance, a “detailed history” requires documentation of the CC, an extended HPI, an extended ROS, and pertinent PFSH.