Reader Questions:
Add PFSH to Determine History
Published on Sat Mar 27, 2010
Question: The cardiologist performed a comprehensive exam and high complexity medical decision making for a new patient who presented with fever and chest pain. He suffered a myocardial infarction (MI) several weeks ago. The cardiologist documented a diagnosis of Dressler's syndrome. If the cardiologist addressed five history of present illness (HPI) elements and reviewed 10 systems (ROS), what is the history level? California Subscriber Answer: CPT bases the history level on HPI, ROS,and personal past, family, and social history (PFSH), so you'll have to review the notes to determine the PFSH level before deciding on a history level. During a "complete" PFSH for a new patient, the physician asks the patient direct questions about all three PFSH elements. If she only asks a new patient about one or two PFSH elements, it is a "pertinent PFSH." You may need to hunt for the PFSH within the body of the HPI [...]
