# Established Patient



## mlemon (Jul 15, 2009)

I recently went to a chart auditing/ e/m coding course where the instructor stated that under the History section of an office note all three sections must agree on the same level.  For example: the HPI, the ROS, and the PFSH must all have the same level of service.  I was under the impression that only 2 of the three must agree.  Which is correct?

Thanks in advance.


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## LLovett (Jul 15, 2009)

On established patients it is only 2 of 3 (History, Exam, MDM), CPT clearly states this. The only time an established patient could be seen and need 3 of 3, that I can think of, would be in a consult or admission. 

History is always 3 of 3. HPI, ROS, PFSH in order to determine level of history.

Laura, CPC


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## kumeena (Jul 15, 2009)

2 out of the 3 means history exam and MDM. Under history you have 3 subcatogries HPI ROS and PFSH


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## dmaec (Jul 15, 2009)

the History Component is "equal to lowest category documented" so even IF you have a:
COMPREHENSIVE - HPI
and a
DETAILED - PFSH
but only an 
EPF - ROS
your HISTORY component is ONLY an EPF.. the "LOWEST" category documented.


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## FTessaBartels (Jul 15, 2009)

*3 of 3 for HISTORY*

You need to meet or exceed 3 of the 3 areas of *History*: HPI, ROS, PMFSH - in order to determine your level of history.

For an established patient (or subsequent hospital visit) you only need to meet 2 of the 3 key elements for the total level of service: History, Exam, MDM.

Hope that helps

F Tessa Bartels, CPC, CEMC


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## Karolina (Jul 17, 2009)

The way I like to explain it is that the level of history is determined in an ascending fashion. 

#1: Chief Complaint
You start with the *chief complaint* - no CC - forget it, cause you can't 
charge for the visit. 

#2: History of Present Illness (HPI)
Once you have the CC you go look for your HPI:
- If you have 1-3 items it is BRIEF
- If you have 4 or more it is EXTENDED. 
With up to 3 HPI your history cannot be greater than EXPANDED PROBLEM FOCUSED, even if the ROS and PFSH are at maximum!

#3: Review of Systems
Next you need the ROS. 
- If you don't find anything, then your maximum level of history is PROBLEM FOCUSED (regardless of the number of HPI you have).
- If you have 1 item, you get EXPANDED PROBLEM FOCUSED (EPF) (again, regardless of the number of HPI items)
- If you have between 2 and 9 ROS and up to 3 HPI it is EPF
- If you have between 2 and 9 ROS and 4 or more HPI and 1 PFSH, your history is detailed.
- If you have between 2 and 9 ROS and 4 or more HPI, but NO PFSH, your history is EPF
- If there is a complete ROS (10 or more items) and 4 or more HPI your history could be COMPRENSIVE depending on how much PFSH is documented.

#4 Past, Family, Social History
- If none is documented, you either have a PF or EPF history, depending on the prior criteria (see above)
- If you have one plus 4 or more HPI plus 9 ROS then the history is DETAILED
- If you have an ESTABLISHED PATIENT/SUBSEQUENT CARE, 2 or 3 PFSH and 4 or more HPI and 10 or more ROS then you have a COMPREHENSIVE HISTORY
- If you have a NEW PATIENT/CONSULT/INITIAL ADMIN, 3 PFSH and 4 or more HPI and 10 or more ROS then you have a COMPREHENSIVE HISTORY

The way I review these is each segment separately and the lowest determines the level of history, which in conjunction with exam and MDM leads to the final code.

I am in agreement with what was previously posted and thought I'd add more detail. Hope this isn't too much.


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