tci ED Coding & Reimbursement Alert - 2004 Issue 12

Reader Question: Collect 3 PFSH for High-Level Observation Codes

Question:  When using either set of observation codes (99234-99236 or 99218-99220) in the ED, should I consider a complete PFSH to be when two of the three history areas are documented - or only when three of the three areas are documented? CPT states that for a "comprehensive" history, I need a chief complaint, an extended history of present illness, a review of systems directly related to the problem identified (and a review of all additional systems), and a complete past, family, and social history.Colorado Subscriber Answer: CPT requires a complete past, family, and social history (PFSH) for...

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