Wiki E/M Level ER

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JulesofColorado

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Ok, let's say patient comes into ER for an earache. The physician doesn't document a PFSH at all. This is for Physician coding. My question is, does this make it a Problem Focused visit or Expanded Problem Focused?
The 1997 Guidelines state that "At least one specific item from any of the three history areas must be documented for a pertinent PFSH."

My Supervisor says I can mark it as an EPF History. I disagree. I think it should be a PF History, automatic Level 1.

Thanks in advance
 
EPF history possible

EPF history requires chief complaint and at least ONE element of HPI AND a problem pertinent ROS. No PFSH required at all.

PF history requires only chief complaint and 1 element of HPI.

F Tessa Bartels, CPC, CEMC
 
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