Wiki History for 99204

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mburgett said:
I need guidance on the following history for a new patient. The provider documented a complete HPI, ROS and past medical history for their patient, but listed the following statement at the end:

Reviewed problem list, meds, family and social history.

Is it enough? Any help will be greatly appreciated!
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I'm sorry I don't have any answers for you but your post does raise some questions.

1. Is the medication list, family and social history in the current chart or on an off-site chart the physician reviewed?
2. If the meds, family hist and social history were generated on site, how were they generated? Was the med list, family history and social history part of the paperwork the patient filled out when they requested an appointment? Was the med list fam hist and soc hist obtain by someone in the office, possibly an employee, cma, cna or scribe?
3. Did the physician determine the 99204 code, or was this determined by a coder?
4. Is this statement standard on all the office/physician notes?
5. Is the note on an emr and the med list, fam hist and soc hist on paper charts?
6. Is the information somehow attached to the current note?
7. Is there a way the med list, family and soc history can be retrieved for each note in the event of an audit?
 
Thank you both! To answer Candle99's questions, yes to most of your questions. We are using an EMR and the information is retrieved on paper and then scanned by our staff, the provider chooses the level of service. I appreciate you both responding. This statement is not standard which is why I asked the question.
 
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Query your doctor if he meant to add a length of time for the review statement he added. It might make the difference between a 99203 and a 99204.

Peace
@_*
 
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