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E/M Level ER

  1. Question E/M Level ER
    Medical Coding Books
    Ok, let's say patient comes into ER for an earache. The physician doesn't document a PFSH at all. This is for Physician coding. My question is, does this make it a Problem Focused visit or Expanded Problem Focused?
    The 1997 Guidelines state that "At least one specific item from any of the three history areas must be documented for a pertinent PFSH."

    My Supervisor says I can mark it as an EPF History. I disagree. I think it should be a PF History, automatic Level 1.

    Thanks in advance

  2. #2
    Location
    Evansville Indiana
    Posts
    451
    Default pfsh
    No PFSH can qualify for EPF. Pertinent or 1 history in the ER is detailed.

  3. #3
    Location
    Milwaukee WI
    Posts
    4,466
    Default EPF history possible
    EPF history requires chief complaint and at least ONE element of HPI AND a problem pertinent ROS. No PFSH required at all.

    PF history requires only chief complaint and 1 element of HPI.

    F Tessa Bartels, CPC, CEMC

  4. Default
    Thank you!

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