Primary Care Coding Alert

Question: I am having trouble deciding between E/M levels for this encounter: The notes clearly indicate that the family physician (FP) performs comprehensive examination and high-complexity medical decision making for a new 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 levelfive E/M?

Indiana Subscriber

Answer: You'll have to review the notes to determine the level of personal 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 history associated with a level-five E/M.

A comprehensive history also requires a complete PFSH, however, which you do not mention in your description.

During a complete PFSH for a new patient, the physician asks the patient direct questions about all three PFSH elements. If she only asks about one or two PFSH elements for a new patient, it is a pertinent PFSH.

Best bet: Count the PFSH elements that the physician documented. If she performed a complete PFSH, report 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity ...) for this encounter with ICD-9 code 411.0 (Postmyocardial infarction syndrome) appended to represent the patient's condition.

You may need to hunt for the PFSH within the body of the HPI or ROS because the information may not be separately marked. If you can only find evidence of a pertinent PFSH for this patient, however, this will only qualify as a detailed history, so you should select 99204 (...a detailed history; a detailed examination; medical decision making of moderate complexity...) with 411.0 appended instead.

-- Information for and answers to You Be the Coder and Reader Questions reviewed by Kent Moore, manager of health care financing and delivery systems for the American Academy of Family Physicians in Leawood, Kan.