Wiki History E/M

[Lyndzee Toone]

I just need a quick refresher as I am studying e/m coding

coding scenerio: (HPI -expf),(Ros-det,)(pfsh-comp3) Do I code to lowest level? So my history portion of my code would only be able to be an expanded problem focus. Correct? Just need to confirm for study purposes.

 

[Pathos]

CMS E/M guidelines explains:

"To qualify for a given type of history all three elements in the table must be met.", you should code at the level where each of the History sub-components meets. If they don't all align, then you should code to the lowest level.

In your example, the History looks like an Expanded Problem Focused, because the History of Illness is shown to be Brief/Expanded Problem Focused.

 

[Lyndzee Toone]

Thank you!