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General Surgery Coding Alert

Reader Question:

Let the Elements Drive Your History Documentation

Published on Sun Feb 27, 2005

Question: The chart that physicians use to select the level of history includes identifiers. For example, under the 1995 guidelines, to support a detailed level of history, documentation must contain at least four recognized elements of the history of present illness (HPI), between two and nine elements of the review of systems (ROS), and at least one element of past, family and/or social history (PFSH).

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.
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