Primary Care Coding 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?

Michigan Subscriber

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

How it works: There are three levels of PFSH: 

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 PFSH areas directly related to the patient’s problem(s).

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

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

Best bet: Count the PFSH elements that the physician documented. If she performed a complete PFSH, report 99205 (Office or other outpatient visit for the evaluation and management of anewpatient, which requires 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 a complete PFSH for this patient, however, this will only qualify at most as a detailed history (assuming the physician documented at least a pertinent PFSH), in which case you should select 99203 (… a detailed history; a detailed examination; medical decision making of low complexity…) for the encounter. If the physician did not document any PFSH, then you are left with an expanded problem focused history, which would only support 99202(…an expanded problem focused history; an expanded problem focused examination; straightforward medical decision making…).

Pointer: The PFSH 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.