Inpatient Facility Coding & Compliance Alert

Question: Is it always required that a family history be documented before assigning code 99220 or 99236 for comprehensive or high complexity observation services? 

New Mexico Subscriber 

Answer: You are correct in that the CMS documentation guidelines say that comprehensive observation services, unlike ED E/M, require three of three PFSH elements for the highest level.  Also CPT® includes these elements in the definition of a comprehensive History, which is required for observation codes.

• Chief complaint;
• Extended history of present illness; 
• Review of systems that is directly related to the problem(s) identified in the history of the present illness plus a review of all additional body systems;
• Complete past, family, and social history.

Only the lowest level of observation, codes 99218 (Initial observation care, per day, for the evaluation and management of a patient which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity)or 99234 (Observation or inpatient hospital care, for the evaluation and management of a patient including admission and discharge on the same date, which requires these 3 key components: A detailed or comprehensive history; A detailed or comprehensive examination; and Medical decision making that is straightforward or of low complexity.) can be billed with a detailed or comprehensive history and physical exam; but what usually drives the observation choice is the level of medical decision making, that is,  low, moderate, or high.