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[DrKitty]

Quick question- how would you code a history if the HPI is brief, the ROS is extended, and the PFSH is pertinent- for an established pt. TIA
Kindly please explain

 

[Pathos]

Hello,

That looks like a Expanded Problem Focused History. All three elements (HPI, ROS, PFSH) must be met to qualify for an E/M level, otherwise the lowest (HPI in this case) will determine the overall History type.

Source:
CMS E/M guidelines

Hope that helps.

 

[DrKitty]

either if its establish patient then too also the lowest will be the selection???

 

[DrKitty]

Hello,

That looks like a Expanded Problem Focused History. All three elements (HPI, ROS, PFSH) must be met to qualify for an E/M level, otherwise the lowest (HPI in this case) will determine the overall History type.

Source:
CMS E/M guidelines

Hope that helps.

either if its establish patient then too also the lowest will be the selection???

 

[Pathos]

Yes, whether the patient is New or Established has little effect on the History (except for getting a Complete Past Medical, Family, Social History).

Medicare pays on what is the least medically necessary, and if either of the three History components (HPI, ROS, PMFSH) is lower than the other two component; then the lowest component will determine the overall History.

 

[DrKitty]

Yes, whether the patient is New or Established has little effect on the History (except for getting a Complete Past Medical, Family, Social History).

Medicare pays on what is the least medically necessary, and if either of the three History components (HPI, ROS, PMFSH) is lower than the other two component; then the lowest component will determine the overall History.

Thank you