Wiki Interval History - Can someone explain Interval history?

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Lynda Wetter

Lynda Wetter

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Can someone explain Interval history?
I know its a history statement regarding the history from last visit to the current visit usually in the subsequesnt hospital setting. What type of credit do you give for that? A complete PFSH? And what would be an example of a statement?
? ? ? IDK
 
An interval history is basically history since the last time you saw them. The documentation requirements are similar. HPI and ROS are scored the same. The only difference is the PFSH

New patient (not an interval history) 1 or 2 elements of PFSH is good enough for a Detailed History, 3 elements of PFSH required for a Comprehensive history

Established patient (interval history) 1 element of PFSH good enough for Detailed history, 2 or 3 elements of PFSH good enough for a Comprehensive history

Note that for subsequent hospital care or subsequent nursing facility care (progress notes) NO PFSH is required. So basically just drop that element of the history. Also, in the Emergency Department, even though the patients are usually new, the requirements are the same as the established patient requirements I outlined above.
 
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Where is it documented that "NO PFSH is required" for subsequent hospital care codes?
Thanks!
 
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Page 8 of the 95 DG's
"For the categories of subsequent hospital care, follow-up inpatient consultations and subsequent nursing facility care, CPT requires only an "interval" history. It is not necessary to record information about the PFSH."


Thanks for the input....Happy Friday!
 
MikeEnos said:
An interval history is basically history since the last time you saw them. The documentation requirements are similar. HPI and ROS are scored the same. The only difference is the PFSH

New patient (not an interval history) 1 or 2 elements of PFSH is good enough for a Detailed History, 3 elements of PFSH required for a Comprehensive history

Established patient (interval history) 1 element of PFSH good enough for Detailed history, 2 or 3 elements of PFSH good enough for a Comprehensive history

Note that for subsequent hospital care or subsequent nursing facility care (progress notes) NO PFSH is required. So basically just drop that element of the history. Also, in the Emergency Department, even though the patients are usually new, the requirements are the same as the established patient requirements I outlined above.
Click to expand...

Can you give an example of what the note may say, like "no change from previous 2/12/13" something like that. And you say to drop that portion from the history section so i just base the HX on the HPI and ROS elements.
Thanks for your help I dont work with these situations and my exam is fast approaching and this is a grey area for me!
 
If it's a hospital progress note, the history may be very brief, something like:
"No overnight events noted. Says he is feeling better, still has intermittent shortness of breath but the chest pain has resolved with medication."

If it's an office follow-up it is usually a bit more detailed. There is more interval history if you last saw them 4 weeks ago compared to if you last saw them yesterday. So you would expect to see at least a sentence or two outlining the patient's condition since the last visit. Better/worse any new symptoms, what has helped or worsened the symptoms, etc.
 
MikeEnos said:
If it's a hospital progress note, the history may be very brief, something like:
"No overnight events noted. Says he is feeling better, still has intermittent shortness of breath but the chest pain has resolved with medication."

If it's an office follow-up it is usually a bit more detailed. There is more interval history if you last saw them 4 weeks ago compared to if you last saw them yesterday. So you would expect to see at least a sentence or two outlining the patient's condition since the last visit. Better/worse any new symptoms, what has helped or worsened the symptoms, etc.
Click to expand...

Thanks Mike as always you are a great resource!
 
An interval history is basically history since the last time you saw them. when patient is admitted in hospital H & P note ie initial hospital visit documentation includes history in detail but on subsequent visits the physician may not ask that much in detailed since he already knows about the patients history from initial day he will just ask about overnight events that is whether his condition is improving or did he noticed any new symptoms etc

the term is generally used in subsequent hospital visit of facility coding.

interval history includes only HPI and ROS , while PFSH is NOT required.

interval history normally includes overnight events in hospital.

Abhishek Rane CPC:cool:
 
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