E/M HPI -help

kiku3@ptd.net

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I remain confused on one point of the history part of the audit sheet; how do you reach a "detailed" designation if there is only EPF (1-3 for brief) and C (4 or more expanded) areas on the audit sheet for the HPI? So many times the provider will reach a brief HPI but a Complete ROS and PFSH? And yet on the New Office/Consult/ER part of level of service there is a column for a Detailed history...how do you reach detailed??? Sorry if this seems simple I just never could understand this!! Thanks for any help.
 

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I remain confused on one point of the history part of the audit sheet; how do you reach a "detailed" designation if there is only EPF (1-3 for brief) and C (4 or more expanded) areas on the audit sheet for the HPI? So many times the provider will reach a brief HPI but a Complete ROS and PFSH? And yet on the New Office/Consult/ER part of level of service there is a column for a Detailed history...how do you reach detailed??? Sorry if this seems simple I just never could understand this!! Thanks for any help.
For a detailed history requires:

Extended HPI
PFSH: Only 1 area required
ROS: 2-9

Is this based on the highest level of service for what your example shows? New office, Consult/ ER?

A detailed history supports:

Office: 99203, 99214
Consult: 99243
H&P: 99221

Hope this helps...
 

kiku3@ptd.net

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Thank you so much, that was the way I was leaning that the HPI had to be extended but I could not find it written anywhere, even in the booklet from CMS, I guess they just assume you would know it!
 
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Hpi, ros, pfsh

Get in the habit of counting in this order HPI - ROS - PFSH

ALL levels of history require a valid chief complaint

Problem Focused History
HPI - 1 to 3 elements

Expanded Problem Focused History
HPI - 1 to 3 elements
ROS - problem pertinent

Detailed History
HPI - 4+ elements
ROS - 2 to 9 systems
PFSH - at least 1 pertinent element

Comprehensive History
HPI - 4+
ROS - 10+
PFSH - at least 1 from EACH of the areas (i.e. Medical, Family & Social histories)
(NOTE - for certain classes of subsequent visit, you only need TWO areas documented)


Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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