Appendix A: HCFA Guidelines for Patient History Level Selection (E&Ms)
 
   

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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