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