Advanced Search

Otolaryngology Coding Alert

Reader Questions:

In the Absence of Details, Rely on Documentation

Published on Wed May 05, 2010

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 SubscriberAnswer: 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), [...]
You’ve reached your limit of free articles. Already a subscriber? Log in.
Not a subscriber? Subscribe today to continue reading this article. Plus, you’ll get:
  • Simple explanations of current healthcare regulations and payer programs
  • Real-world reporting scenarios solved by our expert coders
  • Industry news, such as MAC and RAC activities, the OIG Work Plan, and CERT reports
  • Instant access to every article ever published in your eNewsletter
  • 6 annual AAPC-approved CEUs*
  • The latest updates for CPT®, ICD-10-CM, HCPCS Level II, NCCI edits, modifiers, compliance, technology, practice management, and more
*CEUs available with select eNewsletters.

Other Articles in this issue of

Otolaryngology Coding Alert

View All