NMURPHY8366
Networker
On a new patient, if the outcome is;
hpi; complete
ros; detailed
pfsh; complete
what would the level be?
Thanks
hpi; complete
ros; detailed
pfsh; complete
what would the level be?
Thanks
-
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Wiki History level
- Thread starter NMURPHY8366
- Start date
Pathos
True Blue
Per CMS E/M guidelines:
"History
The Elements Required for Each Type of History table depicts the elements required for each type of history. You can find more information on the activities comprising each of these elements on pages 5–10. To qualify for a given type of history, all four elements indicated in the row must be met. Note that as the type of history becomes more intensive, the elements required to perform that type of history also increase in intensity."
For your example given:
Because the ROS is "Detailed/Extended", the overall History is Detailed despite a complete HPI and PFSH. I am also assuming that an appropriate Chief Complaint was documented.
All of the above should also be medically necessary in order to be considered.
"History
The Elements Required for Each Type of History table depicts the elements required for each type of history. You can find more information on the activities comprising each of these elements on pages 5–10. To qualify for a given type of history, all four elements indicated in the row must be met. Note that as the type of history becomes more intensive, the elements required to perform that type of history also increase in intensity."
For your example given:
- HPI: Complete/Extended
- ROS: Detailed/Extended
- PFSH: Complete
Because the ROS is "Detailed/Extended", the overall History is Detailed despite a complete HPI and PFSH. I am also assuming that an appropriate Chief Complaint was documented.
All of the above should also be medically necessary in order to be considered.