Pulmonology Coding Alert

Question: The E/M guideline chart that we use to select the level of history includes identifiers. For example, to report a problem-focused history, documentation should show a brief 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 elements present in the pulmonologist'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 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 a review of two systems (ROS), and a comment about one of the "histories" (past, family or social) from your pulmonologist.

If the pulmonologist provides a comment about only one ROS, the documentation does not support the requirements for a detailed history.  Therefore, you should select an expanded problem-focused code that  corresponds to the history requirements for 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) because the pulmonologist has met ROS requirements for this level (one to three HPI elements, one ROS, zero PFSH).

Answers for You be the Coder and Reader Questions were reviewed by Carol Pohlig, BSN, RN, CPC, senior coding and education specialist at the University of Pennsylvania department of medicine in Philadelphia; and Alan L. Plummer, MD, professor of medicine, division of pulmonary, allergy and critical care at Emory University School of Medicine in Atlanta.