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Documentation of the patient's history requires:

Answer: d

Documentation of a complete history must include the Chief Complaint, History of Present Illness (HPI), Review of Systems (ROS), and Past, Family, and/or Social History (PFSH). For a new patient encounter all three components, HPI, ROS, and PFSH must meet the requirements to qualify for the specific level of E/M service billed. For example: CPT 99203 requires a detailed history. This means that the HPI must be extended (4 elements or comments on 3 or more chronic or inactive conditions), the ROS must meet the requirements of extended (2-9 systems), and the PFSH must be problem pertinent (one history area documented). If all three do not meet the requirements, then the history portion of the encounter will be down-coded to the lowest documented element (HPI, ROS, PFSH). For instance, if the HPI is extended, the ROS is omitted, and the PFSH is problem pertinent, then the over-all history element would be down-coded to a Problem Focused based on the ROS. A Problem Focused History would cause a new patient visit 99203 to become a 99201.

When coding for an established patient, generally the history is fairly brief and is not used as one of the required two determining elements. The established visits would be selected based on exam and medical decision making (MDM). If the history is going to be used as one of the two determining factors for selection of the established patient encounter, then it must meet the requirements for all 3 components. For example: If a patient is seen and the visit documentation contains little or no exam element, then the determining elements would be the history and MDM. Visit code 99213 would require, for this example, an expanded problem focused history and low medical decision making. If the history is documented as only problem focused, again with the omission of the ROS, then the 99213 encounter would be down-coded to a 99212.

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