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Established Patient

  1. #1
    Default Established Patient
    Exam Training Packages
    I recently went to a chart auditing/ e/m coding course where the instructor stated that under the History section of an office note all three sections must agree on the same level. For example: the HPI, the ROS, and the PFSH must all have the same level of service. I was under the impression that only 2 of the three must agree. Which is correct?

    Thanks in advance.

  2. #2
    On established patients it is only 2 of 3 (History, Exam, MDM), CPT clearly states this. The only time an established patient could be seen and need 3 of 3, that I can think of, would be in a consult or admission.

    History is always 3 of 3. HPI, ROS, PFSH in order to determine level of history.

    Laura, CPC

  3. #3
    2 out of the 3 means history exam and MDM. Under history you have 3 subcatogries HPI ROS and PFSH

  4. #4
    Duluth, Minnesota
    the History Component is "equal to lowest category documented" so even IF you have a:
    and a
    but only an
    EPF - ROS
    your HISTORY component is ONLY an EPF.. the "LOWEST" category documented.
    Donna, CPC, CPC-H

  5. #5
    Milwaukee WI
    Default 3 of 3 for HISTORY
    You need to meet or exceed 3 of the 3 areas of History: HPI, ROS, PMFSH - in order to determine your level of history.

    For an established patient (or subsequent hospital visit) you only need to meet 2 of the 3 key elements for the total level of service: History, Exam, MDM.

    Hope that helps

    F Tessa Bartels, CPC, CEMC

  6. #6
    The way I like to explain it is that the level of history is determined in an ascending fashion.

    #1: Chief Complaint
    You start with the chief complaint - no CC - forget it, cause you can't
    charge for the visit.

    #2: History of Present Illness (HPI)
    Once you have the CC you go look for your HPI:
    - If you have 1-3 items it is BRIEF
    - If you have 4 or more it is EXTENDED.
    With up to 3 HPI your history cannot be greater than EXPANDED PROBLEM FOCUSED, even if the ROS and PFSH are at maximum!

    #3: Review of Systems
    Next you need the ROS.
    - If you don't find anything, then your maximum level of history is PROBLEM FOCUSED (regardless of the number of HPI you have).
    - If you have 1 item, you get EXPANDED PROBLEM FOCUSED (EPF) (again, regardless of the number of HPI items)
    - If you have between 2 and 9 ROS and up to 3 HPI it is EPF
    - If you have between 2 and 9 ROS and 4 or more HPI and 1 PFSH, your history is detailed.
    - If you have between 2 and 9 ROS and 4 or more HPI, but NO PFSH, your history is EPF
    - If there is a complete ROS (10 or more items) and 4 or more HPI your history could be COMPRENSIVE depending on how much PFSH is documented.

    #4 Past, Family, Social History
    - If none is documented, you either have a PF or EPF history, depending on the prior criteria (see above)
    - If you have one plus 4 or more HPI plus 9 ROS then the history is DETAILED
    - If you have an ESTABLISHED PATIENT/SUBSEQUENT CARE, 2 or 3 PFSH and 4 or more HPI and 10 or more ROS then you have a COMPREHENSIVE HISTORY
    - If you have a NEW PATIENT/CONSULT/INITIAL ADMIN, 3 PFSH and 4 or more HPI and 10 or more ROS then you have a COMPREHENSIVE HISTORY

    The way I review these is each segment separately and the lowest determines the level of history, which in conjunction with exam and MDM leads to the final code.

    I am in agreement with what was previously posted and thought I'd add more detail. Hope this isn't too much.
    Karolina, CPC, CPMA, CEMC

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