Orthopedic Coding Alert
Know Your E/M History, or You May Be Doomed to Repeat Filing
Question: If I have a chief complaint, an extended history of present illness (HPI), a problem-pertinent review of systems (ROS), and a complete past, family, and social history (PFSH); do I have enough for a comprehensive history? South Carolina Subscriber Answer: For a comprehensive history, you need to meet or exceed the following four elements: a chief complaint, an extended HPI, a complete ROS, and a complete PFSH. Your scenario matches three of those elements (chief complaint, extended HPI, and complete PFSH), but the problem-pertinent ROS you have documented is lower than the complete ROS needed to justify a comprehensive history. The problem-pertinent ROS element only meets the level required for an expanded problem focused history (which requires a chief complaint and a brief HPI in addition). This means the elements you have are only enough for an expanded problem focused history.
Orthopedic Coding Alert
- ICD-10 2021:
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Vacation Injuries
Question: The orthopedist in the operating room (OR) treats a patient sent from the emergency [...] - Reader Questions:
Look for Incision Before FBR Code Decision
Question: If the surgeon performs a foreign body removal (FBR) with forceps alone during an [...] - Reader Questions:
Know Your E/M History, or You May Be Doomed to Repeat Filing
Question: If I have a chief complaint, an extended history of present illness (HPI), a [...] - Reader Questions:
Duck Pay Cuts With Split/Shared Visit Smarts
Question: Can qualified nonphysician practitioners (NPPs) “split” a service with a physician for Medicare patients. [...] - Reader Questions:
Don't Be Out to Lunch Coding This E/M Service
Question: We reported 99211 for a nurse visit with a Medicare patient when the provider [...]
