Today we will discuss how to code the History.

There are four levels of history recognized in CPT coding:

  • Problem Focused
  • Expanded Problem Focused
  • Detailed
  • Comprehensive

Reimbursement will depend on the level of history documented which I will describe in this tip.

A history is made of different parts and these elements are Chief Complaint, History of Present illness, Review of Systems, and Past Family and/or Social History

The History of the Present illness can have one of two levels, brief and extended.  A brief HPI consist of one to three elements of the HPI. An extended HPI consist of four or more elements of the HPI.  These elements are location, quality, severity, duration, timing, context, modifying factors and associated signs.
There are 3 levels of Review of systems; problem pertinent, extended and complete.  A problem pertinent ROS deals only with the problem documented and an extended ROS, 2 to 9 systems related to the problem concerned.  A complete ROS deals with the problem plus all additional body systems.
There are only two levels of Past Hx, Family Hx and Social Hx (PFSH):  these are pertinent and complete.
            A pertinent PFSH requires one item from at least one of the three areas whereas a complete PFSH, two of the three areas.
Please look at our video below to see how it all comes together.
This will give you a good start on CPT coding in Evaluation and Management Codes.