EM Levels

Sott3935

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I need help understanding certain elements that must be necessary to assign EM Codes.

99202
Expanded Problem Focused History cc HPI 1-3 elements plus problem pertinent ROS. Can somebody explain to me what a problem pertinent ROS system dierectly related to the problem look like a example?

99203 Detailed History says pertinent, past, family history and social history
one of three. Does this mean if family history is present and past and social history is not present this would qualify for a Detailed History?

99204 Comprehensive History says complete past family hx, social hx, and family history 3 of 3 initail and 2 of three established. Does this mean if you do not have all three for a new pt you can not count say that this is a CH. Also if you do not have 2 out of three for a established pt you should not say that this is a CH?

If somebody can help me understand this I would appreciate it.

Thanks
Eddie Sottong
 
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I'll try to help

Problem Pertinent ROS: Let's say your patient has a complaint of "runny nose" ... A problem pertinent ROS might be Fever, headache, sore throat (negative or positive) Any ONE of these tiems would be a problem pertinent ROS.

Detailed History: Yes, you're right. You only need one of the three - past medical, family or social history - to meet the PMFSH component of the detailed history (but you still need the chief complaint and appropriate HPI and ROS).

Comprehensive History: For a NEW patient, yes you need all three elements of the PMFSH to meet the requirements of a comprehensive history (plus the CC and appropriate HPI and ROS). For an ESTABLISHED patient you must have at least two of the PMFSH elements for a comprehensive history (plus CC and appropriate HPI and ROS).

It's actually very black & white. If you don't have all three PMFSH for a new patient you don't have a Comprehensive History.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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Sott3935

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EM Codes

Thank you for taking the time to explain this to me. I now have a better understanding of the process. I will keep practicting till I get it down pat.

Thanks
Eddie
 
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