past, family. social history areas

Pilar10

Contributor
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Hi All,

I just started doing auditing at work and on the auditing worksheet tool I am getting a comprehensive history, comprehensive exam and a moderate decision making which comes out to cpt code 99204. My dilemma is that the doctor only documented a social and family history not the three history areas I need in order for it to be a comprehensive e/m level so would I downgrade the e/m to a 999203? How would this be approached?. Thank you to all for your immediate response.

Pilar CPC, CPMA
 

trarut

Expert
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384
Location
Columbus, OH
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If you don't have a complete PMFSH, you can't have a comprehensive History; at most, it would be detailed. Detailed History + Comprehensive PE + Moderate MDM = a level 3 visit. Are you sure you don't have past medical history described somewhere else in the note?
 

bedforak1

Guru
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118
Location
Nashville, TN
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Are any allergies or medications documented? You can use those for past medical hx. Just make sure not to use allergies for both past history and review of systems.
 

Pilar10

Contributor
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hello,

under the allergy section doctor typed nkda would I be okay to use this. Thank you so much for taking the time to respond.
 
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