• If this is your first visit, be sure to check out the FAQ & read the forum rules. To view all forums, post or create a new thread, you must be an AAPC Member. If you are a member and have already registered for member area and forum access, you can log in by clicking here. If you've forgotten the password it can be reset on our sign in section by entering your registered Email Address or Username here. To start viewing messages, select the forum that you want to visit from the selection below..

Wiki E/M HPI -help

Create Wiki
K

kiku3@ptd.net

Guest
Messages
25
Best answers
0
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.
 
kiku3@ptd.net said:
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.
Click to expand...

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...
 
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!
 
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
 
You must log in or register to reply here.
Top