The requirements are clearly outlined in the CPT book guidelines. Look at the "green pages" of CPT 2009 Professional Edition.
If the patient has completed a history questionaire that is part of the medical record, the provider can reference that information in his/her documentation: e.g. For complete PFSH see patient questionaire completed and reviewed by me today.
If the patient is unable to provide history due to condition, and there are no family members available to provide this information the provider should note the reason s/he is unable to complete the history and credit can be given. E.g. Complete history cannot be obtained due to patient's altered mental status; no family members present to complete/confirm history.
F Tessa Bartels, CPC, CEMC
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