tci Part B Insider - 2010 Issue 6

YOUR PART B QUESTIONS ANSWERED: PFSH Tips Scales on Some E/Ms

Question: I am having trouble deciding between E/M levels for this encounter: The notes clearly indicate that the gastroenterologist performs comprehensive examination and high-complexity medical decision making for a patient with a diagnosis of Crohn's disease of the small and large intestines. As for history, however, I am not sure if the level is comprehensive or detailed. Notes indicate that the gastroenterologist addressed five history of present illness (HPI) elements and reviewed 10 systems (ROS). Is this a level-five E/M? Answer: You'll have to review the notes to determine the level of past personal, family, and social history (PFSH)...

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