General Surgery Coding Alert

Question: I have a surgeon’s note for an office visit that clearly indicates a comprehensive examination and highcomplexity medical decision making for a new patient with a history of diabetes. I am not sure if the history level is comprehensive or detailed. The surgeon addressed five history of present illness (HPI) elements and reviewed 11 systems (ROS). Is this a level-five E/M?

Louisiana Subscriber

Answer: You’ll have to review the notes to determine the level of personal past medical, family, and social history (PFSH) before deciding on an E/M code. You would have to identify a complete PFSH in order to code a level-five E/M service.

How it works: There are three levels of PFSH:

• None: There is no evidence that the physician asked the patient about his past, family, or social history.
• Pertinent: Notes indicate that the physician asked the patient about at least one of the PFSH areas.
• Complete: Notes indicate that the physician asked the patient about two or three PFSH areas. Note that for new patients, the provider must cover all three areas. For established patient encounters, you only need two to reach a complete level of PFSH.

This encounter involved extended HPI and a complete ROS, both requirements for a comprehensive E/M history. A comprehensive history also requires a complete PFSH, which you do not mention in your description. If you read through your review of systems, you may find elements of past or social history that can be used in those categories.

Best bet: Count the PFSH elements that the surgeon documented. If he performed a complete PFSH, report 99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity …) for this encounter. If the physician documented only one or two PFSH elements for this patient, this will only qualify as a detailed history, so you should select 99203 (…a detailed history; a detailed examination; medical decision making of low complexity …) for the encounter. If there is no PFSH, 99202 (an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making) is the highest code you will be able to bill.

Pointer: The PFSH might not have its own section in the notes; most likely, you’ll find this information within the notes documenting the patient’s HPI or ROS.