tci General Surgery Coding Alert - 2018 Issue 5

Reader Question: See if History is Present or Past

Question: I'm new to E/M coding, and I'm confused about where the "current" conditions/symptoms and the "past" conditions/symptoms fit into the code choice. Nebraska Subscriber Answer: The chief complaint (CC), history of present illness (HPI), and review of systems (ROS) parts of an E/M code include notations about any current conditions or symptoms that the patient has. The past, family, and/or social history (PFSH) part of an E/M code describes any conditions the patient has experienced in the past that might be related to the current condition/symptoms. For instance: If the patient presents for treatment of an ankle wound...

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