Practice Management Alert

Question:   I have a claim in front of me that is giving me pause because I cannot decide on an E/M level. The notes clearly indicate that the physician performed a comprehensive examination and high-complexity medical decision making for a new patient with a history of diabetes. I am not sure if the history level is comprehensive or detailed. The physician addressed five history of present illness (HPI) elements and reviewed 11 systems (ROS). Is this a level-five E/M?

Louisiana Subscriber

Answer:  You’ll have to review the notes to determine the level of personal past medical, family, and social history (PMFSH) before deciding on an E/M code. You’ll need to identify a complete PMFSH in order to code a level-five E/M service.

How it works: There are three levels of PMFSH: 

• None: There is no evidence that the physician asked the patient about his past medical, family, or social history. 

• Pertinent: Notes indicate that the physician asked the patient about at least one of the PMFSH areas.

• Complete: Notes indicate that the physician asked the patient about two or three PMFSH areas. Note that for new patients, the provider must cover all three areas. For established patient encounters, you only need two to reach a complete level of PMFSH. 

This encounter involved extended HPI and a complete ROS, both requirements for a comprehensive E/M history. A comprehensive history also requires a complete PMFSH, which you do not mention in your description.

Best bet: Count the PMFSH elements that the physician documented. If she performed a complete PMFSH, report 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a comprehensive history; a comprehensive examination; medical decision making of high complexity …) for this encounter. If you cannot find evidence of complete PMFSH for this patient, however, this will only qualify as a detailed history, so you should select 99214 (… a detailed history; a detailed examination; medical decision making of moderate complexity … ) for the encounter.

Pointer: The PMFSH might not have its own section in the notes; most likely, you’ll find this information within the notes documenting the patient’s HPI or ROS. Remember, however, that you can only count each piece of information once; that means you can’t count something as an HPI element and past history.