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Need help determining detailed history

  1. #1
    Default Need help determining detailed history
    Medical Coding Books
    Our physician coded the ov as 99203 however the consulting firm says we should have used 99202 a detailed history was taken by the m.a. However the dr note does not reflect this. Should the dr's documentation physically state a detailed history was taken in order to code as 99203?

  2. #2
    Rose City (Portland, Oregon)
    It would not be sufficient for the physician to state that a detailed history was performed. He would need to document the elements of a detailed history (4 HPI, 2 ROS, 1 PFSH). The MA can take and document the history BUT, the MD must refer to ROS/PFSH and basically re-obtain the HPI (he could read the MA's note and reiterate what was said but he cannot copy and paste it word-for-word).

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