Wiki Does this qualify for the family/social/past medical history??


Puyallup, WA
Best answers
Our doctor want's to charge a 99214 for this visit. I'm curious if you can use the family history, social history, and personal history when it says just 'no changes' as he did below. Does that qualify or does he have to reference the date of the last time it didn't change. For example if it said Family history, no changes since 01/01/16 visit. I know it's supposed to reference something for the ROS, but I'm just not sure about the history.


Diverticulitis complicated by abscess- treated non-operatively to date. She continues to reasonably well

She needs a colonoscopy- will arrange with Dr. XX for 3 weeks from now.
MiraLax to avoid constipation.

No orders of the defined types were placed in this encounter.

Feeling better. Minimal pain. No real complaints.

PMHx: No changes
PSHx: No changes
Meds: No changes
All: No changes
FamHx: No changes
ROS:No changes

GENERAL APPEARANCE: Alert and oriented x 3. NAD. Appears stated age.

Blood pressure 146/87, pulse 92, temperature 98.2 °F (36.8 °C), temperature source Oral, resp. rate 14.

EYES: No scleral icterus. EOMI, PERRL
ENT: Mucosae moist
NECK: FROM. No thyromegaly. No nodes.
CHEST: CTA Bilaterally
CV: RRR without murmurs, rubs or gallops
ABDOMEN: Some tenderness in the right lower quadrant with deep palpation.
SKIN: No lesions. Dry
NEURO: Nonfocal
PSYCHIATRIC: Normal affect
MSK: FROM. No abnormalities.
RECTAL: Not examined

Studies: None new.
Per the CMS E/M DG's, the date and location of the previous ROS and/or PFSH must be noted:

!DG: A ROS and/or a PFSH obtained during an earlier encounter does not
need to be re-recorded if there is evidence that the physician reviewed
and updated the previous information. This may occur when a
physician updates his or her own record or in an institutional setting or
group practice where many physicians use a common record. The
review and update may be documented by:
• describing any new ROS and/or PFSH information or noting
there has been no change in the information; and
• noting the date and location of the earlier ROS and/or PFSH.