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Orthopedic Coding Alert

Find Your Place in History

Published on Thu Oct 02, 2003

Don't report another E/M service without using this chart (based on Medicare's 1997 Documentation Guidelines for Evaluation and Management Services) outlining the various levels of history as a guide.
 
Remember: History is just one E/M element that determines your code level. You must also document the appropriate examination and medical decision-making elements to justify reporting these codes.

A problem-focused history (99201) includes:
 

  • Chief complaint
     
  • Brief history of present illness (one to three elements)
     (No review of systems or past, family or social  history is required.)
     
    An expanded problem-focused history (99202) includes:
     
  • Chief complaint
     
  • Brief history of present illness (one to three elements)
     
  • Problem-pertinent review of systems (one system) (No past, family, social history is required.)

    A detailed history (99203) includes:
     

  • Chief complaint
     
  • Extended history of present illness (four or more elements, or three or more chronic or inactive conditions if 1997 Medicare E/M guidelines are being followed)
     
  • Problem-pertinent system review extended to include a review of a limited number of additional systems (two to nine systems)
     
  • Pertinent past, family, and/or social history directly related to the patient's problems (one or two areas of history)
     
    A comprehensive history (99204, 99205) includes:
     
  • 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 (more than 10 systems)
     
  • Complete past, family and social history (two or three history areas).

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