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E&M Help

  1. Default E&M Help
    Medical Coding Books
    I am a CPC-H with 20 years of ASC coding experience. I have a friend who is newly certified and asked me an E&M question that I can't answer. Would someone help me out? I'll repay with surgery coding <grin> Her question is:

    I am trying to find some kind of documentation that says that when choosing your history level for E/M that if all three elements are not met then do you go to the lowest level. I have found on CMS's website that states all three elements have to be met but it doesn't specify if all three elements are not met were you go from there. I hope that you understand what I am trying to say, I feel like I am talking in circles.

  2. #2
    I think your friend is very confused!

    First, all the information she needs is in pages 1-8 of the AMA CPT, "Determine the Extent of History Obtained" is on page 7. There are no "three elements" pertaining to history.

    BUT, there are tree elements to determining the level of E/M service.

    For a New Patient all three elements must be met, no excuses, no way around. If one of the three elements is lower than the other two the lower must be used. For an Established Patient only two of the criteria need to be met.

    Remember that all required aspects of a CPT code MUST BE MET OR EXCEEDED in order to apply that code.

    All she has to do is read the CPT.
    Last edited by jonvieve; 07-21-2009 at 03:37 PM.

  3. #3
    Columbia, MO
    There are actually 4 COMPONENTS to history .. CC, HPI, ROS, PFSH, there must be documentation of the CC or there is no history, other than that the lowest of the other three determines the level of history.

    Debra A. Mitchell, MSPH, CPC-H

  4. #4
    The 3 components of the history are history of present illness (HPI), review of systems (ROS) and past, family and social history (PFSH). In order to qualify for any level of history, you need a specific amount of documentation from each of those areas.

    The levels of history are problem focused (1-3 HPI), expanded problem focused (1-3 HPI and 1 ROS), detailed (4+ HPI, 2-9 ROS and 1 PFSH) and comprehensive (4 HPI, 10+ ROS, complete PFSH).

    What I think she is referring to is, for example, a detailed history requires 4+ HPI, 2-9 ROS and 1 PFSH. If 3 HPI elements were documented with 2-9 ROS and 1 PFSH, you couldn't get a detailed history because you didn't meet the minimum requirements for that level, since you only had 3 HPI. I don't know if it's documented anywhere, but the requirements are the minimum for that level and if you don't meet it you have to go down until you get to a level you do meet. You don't necessarily have to go to the lowest level. It depends on the documentation.
    Pam Tienter, CPC, COC, CPC-P, CCS-P, CPMA, CPC-I, AAPC Fellow
    National Advisory Board Member 2018-2021, Region 6 Great Lakes
    Minneapolis AAPC Chapter, Education Officer 2018
    AHIMA ICD-10-CM/PCS Trainer
    AAPC National ICD-10 Trainer

  5. #5
    Originally Posted by Karolina
    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 recently posted the above in response to a different, similar question, it might apply here as well.
    Karolina, CPC, CPMA, CEMC

  6. #6
    Ok - so my prior comment is all about finding the level of history which is the first of the three key elements (exam and medical decision making are the other two).

    The documentation guidelines should help shed some light on this and can be found on CMS's website. I try to put the link below:

    (If the link doesn't work, try to cut&paste it into the address line.)

    Look under downloads, there should be 1995 guidelines and 1997 guidelines. Both valid and great resources for E/M coding. Maybe a bit cumbersome to follow at first, but don't give up!

    Hope this is useful!
    Karolina, CPC, CPMA, CEMC

  7. #7
    Again, I will say: Read "Determine the Extent of History Obtained" on page 7 of the AMA CPT.

    And yes, it is documented that all of the Key Components must be met or exceeded on page 7 "Select the Appropriate Level of E/M Services Based on the Following."

  8. #8
    Quote Originally Posted by jonvieve View Post
    Again, I will say: Read "Determine the Extent of History Obtained" on page 7 of the AMA CPT.

    And yes, it is documented that all of the Key Components must be met or exceeded on page 7 "Select the Appropriate Level of E/M Services Based on the Following."

    I agree with Karolina. The cms website will have info that is closer to explaining what it is you are actually looking for. I think some of the people that replied to your post missed what it was that your friend was trying to find out. Go to the cms website. There is a lot of good info there, it just might take a little while to weed thru to find what it is you're looking for. Good luck

  9. #9
    I uploaded a couple of .pdf documents from my collection that might be of use:

    I deleted the links due to an offensive pop-up - will re-up to a different host

    Last edited by lonewolf; 07-22-2009 at 01:27 PM.

  10. #10
    Your friend is exactly right, and cms clearly states "To qualify for a give type of history all three elements in the table must be met." So if you take the table they give you in the guidelines and replace the terms they use with the following information.

    Hpi Brief= 1-3 elements, Extended= 4+
    Ros N/A= 0, Problem pertinent= 1, Extended= 2-9, Complete=10+
    PFSH N/A=0, Pertinent= 1, Complete=2+(est pt) or 3 (new/consult)

    Then you can determine what level of history you have, all three must meet or excede in order to support the level. The lowest one met is the level you choose.

    So if you have 4 elements of HPI, 1 ROS, and 3 PFSH, you are stuck at EPF because the ROS is your lowest level.

    This really isn't that confusing and I teach this all the time but it is so hard explaining it when I can't show you what I mean.

    Anyway just trying to help, I find using the chart is the easiest way to determine the level.

    Laura, CPC

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