I am having difficulty coding the level of history for established patients.

When using the Medicare E/M Score sheet what is the difference between problem focused and expanded problem focused ROS in an ophthalmology exam?

For example; the patient comes to the office for an IOP check without any complaints. Would you score EPF; pertinent to problem – 1 system (eyes) or would you say Problem Focused; none.

We only score problem focused if the doctor did not sign our ROS form that the patient completes.

Established patient w/o any complaints:

History: Problem focused
Exam: Comprehensive
MDM: Straightforward
CPT Code: 99212

Or

History: Problem Expanded
Exam: Comprehensive
MDM: Straightforward
CPT Code: 99213

Or

Does the History not matter and you choose the CPT Code based on the MDM – and it would be 99212?