ED Coding and Reimbursement Alert

Question: What documentation is required for the history portion of subsequent hospital visits? What is meant by problem-focused interval history or detail interval history?

Arkansas Subscriber
 
Answer: Interval history refers to the change in the patient's history since the last history was taken. Per CPT guidelines, all levels of subsequent hospital care include reviewing the medical record and reviewing the results of diagnostic studies and changes in the patient's status since the last assessment by the physician.
 
According to the AAPC Independent Study program, when subsequent care is reported the physician should assess the patient's response to therapy. If the patient is improving, the lowest level should be selected. If a minor complication, poor response to treatment, new complaint or abnormal test result from a presentation, select the second level. If the patient deteriorates, becomes unstable or presents a new significant problem, the highest level of service may be reported. Good documentation must support this level of service. If level three is inadequate for the severity of the complication, consider critical care if the patient's condition and amount of time spent support the code selection. Remember that the code selected must be based on the documentation of the complexity of the visit. Do not rely on generalizations alone about the patient's situation to select the code.