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Wiki History level

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NMURPHY8366

Networker
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On a new patient, if the outcome is;
hpi; complete
ros; detailed
pfsh; complete

what would the level be?

Thanks
 
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:

  • 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.
 
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