Cardiology Coding Alert
Let the Elements Drive Your History Documentation
What should we do if the levels of HPI, ROS and PFSH don't match identically to the chart? How should I determine the levels?
Virginia Subscriber
Answer: You should assign the level of history according to the elements present in the physician's documentation (HPI, ROS, PFSH).
In the history section, the components must meet or exceed all of the listed requirements. If the documentation is deficient in one of the elements, that element will limit the level of history supported by the note.
Cardiology Coding Alert
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