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wynonna

True Blue
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540
Location
Hinsdale, MA
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For History, note only documents "NO new complaints" for a subsequent visit.
How do we count this under HPI and ROS? (problem focused or Expanded problem-focused?)
Pt now off ventilator.
thank you
 
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If the only history information is "no new complaints", then I don't think you can use history at all to level your visit.
Problem focused requires chief complaint, 1-3 HPI, 0 ROS, 0 PFSH
Expanded problem focus requires chief complaint, 1-3 HPI, 1 ROS, 0 PFSH
I would level the visit based on exam and MDM only for 99231-99233 as subsequent hospital visits require only 2 of 3 from history, exam & MDM.
I like this article about history https://www.the-hospitalist.org/hospitalist/article/124659/brief-history
I would like to point out the information does not necessarily need to be under the "history" heading of the note and it's possible there is documentation of history elsewhere in the note.
 
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