Part B Insider (Multispecialty) Coding Alert

Question: I am having trouble deciding between E/M levels for this encounter: The notes clearly indicate that the gastroenterologist performs comprehensive examination and high-complexity medical decision making for a patient with a diagnosis of Crohn's disease of the small and large intestines. As for history, however, I am not sure if the level is comprehensive or detailed. Notes indicate that the gastroenterologist addressed five history of present illness (HPI) elements and reviewed 10 systems (ROS). Is this a level-five E/M?

Answer: You'll have to review the notes to determine the level of past personal, family, and social history (PFSH) before deciding on an E/M code. This encounter involved extended HPI and a complete ROS, both requirements for a comprehensive new patient E/M. A comprehensive history also requires a complete PFSH, which you do not mention in your description.

During a complete PFSH, the gastroenterologist asks the patient direct questions about all three PFSH elements: personal medical history, family history, and social history. If she asks only about one or two PFSH elements, it is a pertinent PFSH.

Best bet: Count the PFSH elements that the gastroenterologist documented. If she performed a complete PFSH, report 99205 (Office or other outpatient visit for the evaluation and management of a new patient ...) for this encounter with 555.2 (Regional enteritis; small intestine with large intestine) appended to represent the patient's condition.

You may need to hunt for the PFSH within the body of the HPI or ROS because the information may not be separately marked. If you cannot find evidence of complete PFSH for this patient, however, this will only qualify as a detailed history, so you should select 99203 (... a detailed history; a detailed history; medical decision making of low complexity ... ) with 555.2 appended.