tci General Surgery Coding Alert - 2016 Issue 5

Reader Question: Focus on PFSH for E/M Code Selection

Question: The surgeon’s office visit note indicates a comprehensive examination and high-complexity medical decision making for a new patient with a history of diabetes. I am not sure if the history level is comprehensive or detailed. The surgeon addressed five history of present illness (HPI) elements and reviewed 11 systems (ROS). Is this a level-five E/M? Louisiana Subscriber Answer: You’ll have to review the notes to determine the level of personal past medical, family, and social history (PFSH) before deciding on an E/M code. You would have to identify a complete PFSH in order to code a...

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