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What level history do you get? Consult code

  1. Default What level history do you get? Consult code
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    Chief complaint: Lower Back Pain

    History: The patient is a 56-year old gentleman, who has been having gradually increasing problems with lower back pain episodes, occasionally with sciatic pain in his right leg. the most recent episode resulted in marked back pain, spasm, and inabilty to stand up straigh; it occurred yesterday and resulted in his hospitalization.

    The patient indicates currently that his lower back is substantially improved with inital hosptial treatment. There are no neurologic complaints, and no bowel or bladder dysfuntion.

    Past Medical history:
    1) hypertension
    2) hypercholesterolemia
    3) osteoarthritis

    Past Surgical history:
    1) knee surgery
    2) Tonsillectomy

    Allergies: none known

    Medications: There are 4 listed

    Family history: He has an aunt with back disease.

    Social history: Nonsmoker.

    Review of systems: Otherwise in good health.

  2. #2
    Detailed, because of the ROS.

    Laura, CPC, CEMC

  3. #3
    Milwaukee WI
    Default ROS limits you to Detailed
    I agree with Laura. The ROS limits you to Detailed history. "Otherwise in good health" does not count at all.

    I counted "no neurologic complaints, and no bowel or bladder dysfuntion." as ROS.

    F Tessa Bartels, CPC, CEMC

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