Appendix A
HCFA Guidelines for Patient History Level Selection (E&Ms)
The Health Care Financing Administration has recently produced guidelines which address the level of history recommended for each particular evaluation/management code. The HCFA guidelines specify which factors must be included to qualify for a particular history, as well as the documenting factors which must be included. The history is one factor which determines proper evaluation/management code selection. The factors and their use are summarized in the chart below:
|
Possible choices for E/M code |
Type of History [used to determine proper E/M code] |
History of Present Illness [HPI] • the location of the problem • the quality • the severity of the problem • the duration of the problem • the timing of the problem • the context • modifying factors • associated signs and symptoms |
Review of Systems [ROS] • eyes • ears, nose, throat and mouth • cardiovascular • respiratory • gastrointestinal • genitourinary • musculoskeletal • integumentary • neurologic • psychiatric • endocrine • hematologic or lymphatic • allergic or immunologic |
Past Family and/or Social History [PFSH] • Past history • Family history • Social history |
|
99201 (New) * 99212 (Established) |
Problem-focused |
Brief (1-3 of the above factors) |
N/A |
N/A |
|
99202 (New) 99213 (Est) |
Expanded problem-focused |
Brief (1-3 of the above factors) |
Problem-pertinent (1 of the above systems reviewed ) |
N/A |
|
99203 (New) 99214 (Est) |
Detailed |
Extended (4 or more of the above factors) |
Extended (2-9 of the above systems reviewed) |
Pertinent (1) |
|
99204 (New) 99205 (New) 99215 (Est) |
Comprehensive |
Extended (4 or more of the above factors) |
Complete (10 or more of the above systems reviewed) |
Complete (2 or 3) |
* A "New Patient" (NP) is that patient which has not received any treatment in your clinic...ever, or for at least 36 months prior to today. After the use of a "New Patient" E&M code (99201-05) at the first visit, the patient then becomes an "Established Patient", and the 99211-99215 servies should be used to describe all re-exams and reassessments.
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