Otolaryngology Coding Alert

Question: The E/M guideline chart that we use to select the history level includes identifiers. For example, to report a problem-focused history, documentation should show a brief history of  present illness (HPI), no review of systems (ROS), and no past, family and/or social history (PFSH). What should we do if the levels of HPI, ROS and PFSH don't match the chart? How should we determine the levels?

Louisiana Subscriber

Answer: You should select the level of history according to the elements present in the allergist's documentation (HPI, ROS, PFSH). The components must meet all of the requirements for a specific level for you to submit a claim for that level. If the patient's chart lacks one of the elements, your choice depends on the element the chart is missing.

Example: A detailed history requires a minimum of four HPI elements (or the status of three or more chronic conditions when using 1997 guidelines), a review of at least two systems (ROS), and a comment about one of the "histories" (past, family or social) from your allergist.

If the allergist comments about only one ROS, the documentation does not support the requirements for a detailed history. Therefore, you should select an expanded problemfocused code that corresponds to the history requirements for 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) because the allergist has met ROS requirements for this level (one to three HPI elements, one ROS, zero PFSH).