Primary Care Coding Alert

Question: The chart that we use to select the level of history includes identifiers. For example, to report a problem-focused history, documentation should show a 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 elemeEnts present in the family physician'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 specific level. If the patient 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), at least two ROS, and a comment about one of the "histories" (past, family or social). 

If the documentation provides a comment about only one ROS, such as the eyes, the documentation does not support the requirements for a detailed history. Therefore, you should select an expanded problem-focused code (such as 99213, Office or other outpatient visit for the evaluation and management of an established patient ...) because the physician has met ROS requirements for this level (one to three HPI elements, one ROS, zero PFSH)
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Answers to You Be the Coder and Reader Questions provided by Pamela J. Biffle, CPC, CCS-P, ACS-DE, approved PMCC instructor, product development director of Custom Coding Books in Bellevue, Wash.; Barbara J. Cobuzzi, CPC, CPC-H, CHBME, president of Cash Flow Solutions, a physician reimbursement company in Brick, N.J.; Margaret Kleis, coding analyst at the American Osteopathic Association; and Kent J. Moore, manager of Health Care Financing and Delivery Systems for the American Academy of Family Physicians in Leawood, Kan.