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Comprehensive History requirement

  1. #1
    Default Comprehensive History requirement
    Medical Coding Books
    I am hoping someone can shed some light on this. I have always followed the 97 guidelines, never really paid much attention to CPT E/M guidelines. Today I was researching split/shared E/M on the inpatient side and ran across the following from Medicare.

    "to bill a Level 5 new patient visit, the history must meet CPT's definition of a comprehensive history"

    "The comprehensive history must include a review of all the systems..."

    link to the full document the above is from the last page

    This made me look at CPT's definition. Sure enough CPT's definition states "Comprehensive: Chief complaint; extended history of present illness; review of systems that is directly related to the problem(s) identified in the history of present illness plus a review of all additional body systems; complete past, family, and social history."

    The 97 guidelines state at least 10 systems count as comprehensive.

    Who trumps who? Based on their wording, it looks like, for Medicare, CPT definition would override the 97 guidelines.

    Any insight or opinions are greatly appreciated.


    Laura, CPC

  2. #2
    Every seminar, book & auditor i have talked to that use 97 guidelines say 10 ROS so that is what i use. When we were audited by medicare the auditors didnt say a thing about it and we had several high levels audit with just 10 ROS.

  3. #3
    Thats good to know about the audit.

    I have checked with some auditors that have worked with the OIG and they say Medicare isn't actually following CPT guidelines even though they say they do in the above referenced document.

    It is really hard to educate providers on how to do the right thing with all this conflicting information out there.

    I have done a lot more research in recent months because I am dealing with outside coding companies that are located in different states. It is amazing to me how different the requirements are from carrier to carrier.


    Laura, CPC

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