Internal Medicine Coding Alert

Published on Sun Nov 21, 2004 PDF

Question: The chart that physicians use to select the level of history includes identifiers. For example, to determine a problem-focused history, documentation should show a history of present illness (HPI), no review of systems (ROS), and no past, family and/or social history (PFSH).
 
What should we do if the levels of HPI, ROS and PFSH don't match identically to the chart? How should I determine the levels?
Louisiana Subscriber

Answer: You should select the level of history according to the elements present in the physician's documentation (HPI, ROS, PFSH). 
 
The components must meet all of the requirements for a specific level for you to submit a claim for that specific level. If the patient lacks one of the elements, your choice depends on the element the chart is missing.
 
For example, a detailed history requires a minimum of four HPI elements (or the status of three chronic conditions when using 1997 guidelines), at least two ROS, and a comment about one of the "histories" (past, family or social). 
 
Solution: If the documentation provides a comment about only one ROS, the documentation does not support the requirements for a detailed history.
 
Therefore, you should select an expanded problem-focused code because the physician has met ROS requirements for this level (one to three HPI elements, one ROS, zero PFSH).