Not 99215
Tiffany,
For a comprehensive history you must have 4+ elements of HPI (or status of 3 chronic conditions if you are using the 1997 guidelines for your exam) - AND - a complete ROS (10+ systems reviewed and documented) - AND= a complete PFSH (at least 1 item in EACH category past medical, family and social history).
But your question is far more complex than just whether you have a comprehensive history. I recommend the following:
CPT professional edition (2009) Evaluation and Management (E/M) Services
Guidelines begin on page 1 (green paper in my version) and outline all the various requirements for E/M coding. The
Instructions for Selecting a Level of E/M Service begin on page 5;
Determine the Extent of History Obtained is on pg 7.
www.emuniversity.com has a wealth of information as well on how to pick your level of service.
Google
1997 E/M Guidelines and
1995 E/M Guidelines. Print them out, study them, refer to them.
For an established patient visit, 99215, you must have TWO out of three:
Comprehensive History, Comprehensive Exam, High Complexity MDM.
OR you must have documentation that support coding based on time spent in counseling & coordination of care.
Hope that helps.
F Tessa Bartels, CPC, CEMC