Advanced Search

Primary Care Coding Alert

READER QUESTIONS:

PFSH Puts Added Value on Some E/Ms

Published on Fri Jan 01, 2010

Question: I am having trouble deciding between E/M levels for this encounter: The notes clearly indicate that the family physician (FP) performs comprehensive examination and high-complexity medical decision making for a new patient with a possible myocardial infarction (MI) who had suffered an MI five years earlier; the physician's final diagnosis is Dressler's syndrome. I am not sure if the history level is comprehensive or detailed. The physician addressed five history of present illness (HPI) elements; and reviewed 10 systems (ROS). Is this a levelfive E/M? Indiana Subscriber Answer: You'll have to review the notes to determine the level of personal past, 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 history associated with a level-five E/M. A comprehensive history also requires a complete PFSH, however, which you do not mention in your description. [...]
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 Revenue Cycle Insider
  • 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

Other Articles in this issue of

Primary Care Coding Alert

View All