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patient history
- Thread starter DebraB
- Start date
Laureen
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Blitzer
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Often when they say "brief" it pertains to HPI - History of Present Illness
You are correct in that it is not a recognized level for overall history which would be Problem Focused, Expanded Problem Focused, Detailed or Comprehensive
If you have a full note you want to share I can help more. I'd look to see if they document review of systems at all and did they document any PFSH. If so then I'd consider "brief history" to mean "brief HPI".
You are correct in that it is not a recognized level for overall history which would be Problem Focused, Expanded Problem Focused, Detailed or Comprehensive
If you have a full note you want to share I can help more. I'd look to see if they document review of systems at all and did they document any PFSH. If so then I'd consider "brief history" to mean "brief HPI".
Mr. Sanchez is referred by his family physician to a general surgeon regarding a recurrent femoral hernia on the left side that seems to need surgical repair. Dr. Runs did a brief problem focused history of the present illness and a problem focused exam was performed at the internal medicine clinic. A straightforward MDM was done and a decision for surgery was made. Which CPT code would be used?
This is a questions from your E & M test. This is the one I am referring to.
This is a questions from your E & M test. This is the one I am referring to.
Laureen
Queen Instructor
Staff member
Administrator
Moderator
Blitzer
PBC Student (CPC®)
CCO Club Member
CCO Support Staff
MTA Student
ICD-10-CM Student
PPM Student (CPPM®)
FBC Student (CPC-H®)
Ok so it says Brief history of present illness (HPI) - if you look at the chart above you'll see a brief HPI is on the P(problem focused) or E (expanded problem focused) level. Since there is no ROS or PFSH documented (none for both of those) you would have to consider it at the Problem focused level.
If you're using my method (Locate your HEM in Time) you're trying to fill in the blanks as follows:
Locate (location or category/subcategory) = Office consult
H (History) = P (problem focused) - per explanation above
E (Exam) = P (problem focused) - per scenario above - they just gave it to you
M (Medical Decision Making) = S (straightforward) - per scenario above - they just gave it to you
So you're looking for a PPS in the office consult range - which would be 99241.
The key here is the question said brief HPI not brief history. HPI is just one third of the History piece. And in turn History is one third of the overall EM code.
I hope that helps.
If you're using my method (Locate your HEM in Time) you're trying to fill in the blanks as follows:
Locate (location or category/subcategory) = Office consult
H (History) = P (problem focused) - per explanation above
E (Exam) = P (problem focused) - per scenario above - they just gave it to you
M (Medical Decision Making) = S (straightforward) - per scenario above - they just gave it to you
So you're looking for a PPS in the office consult range - which would be 99241.
The key here is the question said brief HPI not brief history. HPI is just one third of the History piece. And in turn History is one third of the overall EM code.
I hope that helps.