AAPC - Back to school
Results 1 to 3 of 3

Thread: What level history do you get? Consult code

  1. #1

    Default What level history do you get? Consult code

    AAPC: Back to School

    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
    Join Date
    Apr 2007


    Detailed, because of the ROS.

    Laura, CPC, CEMC

  3. #3
    Join Date
    Apr 2007
    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

Similar Threads

  1. Level of History
    By christinec in forum E/M
    Replies: 1
    Last Post: 06-16-2015, 06:55 AM
  2. Help w/history component of hosp consult
    By bbarnard in forum E/M
    Replies: 1
    Last Post: 03-06-2014, 07:44 AM
  3. level of history
    By soprano in forum E/M
    Replies: 2
    Last Post: 08-30-2012, 08:48 PM
  4. History Level??
    By A_Warren in forum E/M
    Replies: 17
    Last Post: 10-12-2010, 02:20 PM
  5. What level of history do you get??
    By kjstearns in forum E/M
    Replies: 1
    Last Post: 05-07-2010, 12:58 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.