Primary Care Coding Alert

Question: A patient presents complaining of a swollen and sore wrist with symptoms lasting one week. Although my family physician (FP) states "no history of trauma," he also notes that the patient was involved in a motor-vehicle accident last month, which he believes is unrelated to the injury. Should I consider the history documentation part of the physician's review of systems or past, family, social history?

Massachusetts Subscriber

Answer: Per CPT, the review of systems is "an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced." The documentation of the motor-vehicle accident does not fit this definition and is more consistent with the CPT conception of past history, which is a review of the patient's past experiences with illnesses, injuries, and treatments. Thus,the FP could consider the comment part of past history or not at all.