All about Evaluation and Management (E and M) procedure codes. Office visit, hospital visit, Hospital care procedure codes. Service codes 99201,99203,99205, 99211, 99212, 99213, 99214, 99215,99221, 99222, 99223, 99231, 99233, 96150 - 96154, G0425 - G0427. How and what code to use for proper E & M Billing.
Wednesday, May 25, 2016
Notes on the Documentation of History
** The CC, ROS, and PFSH may be listed as separate elements of history or they may be included in the description of the history of the present illness.
** A ROS and/or a PFSH obtained during an earlier encounter does not need to be rerecorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record.
The review and update may be documented by:
• Describing any new ROS and/or PFSH information or noting there has been no change in the information; and
• Noting the date and location of the earlier ROS and/or PFSH.
** The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.
** If the physician is unable to obtain a history from the patient or other source, the record should describe the patient’s condition or other circumstance which precludes obtaining a history.
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