Wiki New patient missing some of 3key components

[mmhubb]

If all 3 key components are not present for a new patient, aren't I supposed to drop level of service to lower level established patient code (99212)?

New pediatric pt came in for an ER follow up of laceration to eyebrow; suture removal. Physician coded level of service as 99203 with no ROS or History. Exam is problem focused (limited to affected body area).
I thought I read somewhere that the ability to use level of service for a new pt is forfeited if you leave out these bits of information...

 

[Lashel]

if you can pull out one HPI element, that would work a problem focused history. I would think location must be documented, and that would satisfy HPI problem focused. There is no ROS or PFSH required for the problem focused history. All that is required is 1-3 HPI elements such as "laceration of the forehead (location)" You already have your problem focused exam, and now you just need to figure our your MDM.

Lashel
CPC CPC-I CEMC CPPM

 

[mmhubb]

My apologies... I am refering to the History component (one of the 3 key); there is insufficient documentation. For a new patient, I thought all of the components of the History (HPI, ROS & PFSH) had to be addressed. I probably could get a couple of ROS elements if I pull them from the HPI, but as for the PFSH don't I need all three areas (past,family and social history) for a new patient?

 

[OCD_coder]

Documentation for the History component only for a 99203 requires a Detailed level. This entails 4 HPI elements, 2 ROS and at least 1 history element. Querying whether the patient was up to date on a tetanus shot would support a Past medical history. Or, documenting something like "patient fell while skateboarding" would support Social history. They are pertinent to the presenting problem.

If you can get at least 1 HPI element - Problem Focused history = 99201
If you can get 1 HPI element + 1 ROS - Expanded Problem Focused history = 99202