General Surgery Coding Alert
Focus Comprehensive History Requirements
Question: I have a surgeon’s note for an office visit that includes a chief complaint, an extended history of present illness (HPI), a problem-pertinent review of systems (ROS), and a complete past, family, and social history (PFSH). Is that enough information for a comprehensive history? Codify Subscriber Answer: For a comprehensive history, you need to meet or exceed the following four elements: a chief complaint, an extended HPI, a complete ROS, and a complete PFSH. Your scenario matches three of those elements (chief complaint, extended HPI, and complete PFSH), but the problem-pertinent ROS you have documented is lower than the complete ROS needed to justify a comprehensive history. The problem-pertinent ROS element only meets the level required for an expanded problem focused history (which requires a chief complaint and a brief HPI in addition). This means the elements you have are only enough for an expanded problem focused history.
General Surgery Coding Alert
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