What is an expanded problem focused interval history?

Answer: It is a history that does not require past medical, family, or social history. CPT^® wording is, “an interval expanded focused history” or “an interval detailed history,” depending on the level of visit. The definition of an interval history is found in the Documentation Guidelines, and here is the citation.

Just so, what is an expanded problem focused history?

The Expanded Problem Focused History is the second lowest level of history. This history requires a chief complaint, a brief HPI (containing one to three HPI elements), plus one ROS. No PFSH is required.

One may also ask, what does interval history mean? An interval history is what happened to the patient between the time the MD visits. It usually reads something like: patient had a good night according to patient, family, nursing staff, etc. Or can also be reports of SOB, tacchycardia during the night but now reporting normal.

Likewise, people ask, what is a problem focused history?

The Problem Focused History is the lowest and least descriptive level of history. This history requires only a chief complaint and a Brief HPI (which requires one to three HPI elements). No ROS or PFSH are required. Notice that a chief complaint is clearly stated and only one HPI element (location) is utilized.

What are the 4 levels of history in E&M coding?

The four recognized levels of history are problem-focused, expanded problem-focused, detailed, and comprehensive. The number of elements documented in the progress note determines level selection.

25 Related Question Answers Found

What are the four levels of history?

The levels of E/M services are based on four levels of history (Problem Focused, Expanded Problem Focused, Detailed, and Comprehensive).

What defines a detailed exam?

The level of detail involved in an exam is a clinical judgment based on the documentation for each individual medical record. There is an expectation that the exam will be more involved, and therefore more documentation would be submitted for a detailed exam.

What is a detailed history?

The Detailed History is the second highest level of history and requires a chief complaint, an extended HPI (four HPI elements OR the status of three chronic or inactive problems - if using the 1997 E/M guidelines), plus TWO to NINE ROS, plus at least ONE pertinent element of PFSH .

What are modifying factors for HPI?

A: An essential part of evaluation and management (E/M) documentation is history of present illness (HPI). Two of the eight HPI elements are context and modifying factors.

The other elements of the HPI are:

Location.
Duration.
Quality.
Severity.
Signs and symptoms.
Timing.

What is a detailed physical exam?

The focused physical exam is generally reserved for medical patients or those trauma patients who have a limited number of body systems involved in their trauma. As a result, you should plan to perform a detailed physical exam when cataloging his injuries.

What is straightforward medical decision making?

There are four types of medical decision making: Straightforward – Minimal management options; minimal or no data to review; minimal risk of complications and/or morbidity or mortality. Low Complexity – Limited management options; limited data to review; low risk of complications and/or morbidity or mortality.

How many systems are in a physical exam?

Because a detailed exam ought to include more organ systems than the expanded problem-focused exam, many experts suggest that five to seven systems would be most appropriate for the detailed exam. Some CMS contractors also specify five to seven organ systems for a detailed examination.

What does Chief Complaint mean?

The chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician-recommended return, or other reason for a medical encounter. In some instances, the nature of a patient's chief complaint may determine if services are covered by medical or vision insurance.

What is a problem focused exam?

Problem focused exam – a limited exam of the affected body area or organ system. Detailed exam – an extended exam of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s).

What is a focused exam?

Rapid Trauma Assessment or a Focused Assessment is needed, Physical Exam. assess the patient's chief complaint, assess medical patients. complaints and signs and symptoms using OPQRST, obtain a baseline set of vital signs, and perform a SAMPLE history.

What is the E&M code?

E/M stands for “evaluation and management”. E/M coding is the process by which physician-patient encounters are translated into five digit CPT codes to facilitate billing. CPT stands for “current procedural terminology.” These are the numeric codes which are submitted to insurers for payment.

What is an interval history and physical?

Definition. 1. Interval history: data collection that occurs at subsequent visits to one in which comprehensive history and physical examination were completed.

What are the 8 elements of HPI?

CPT guidelines recognize the following eight components of the HPI:

Location. What is the site of the problem?
Quality. What is the nature of the pain?
Severity.
Duration.
Timing.
Context.
Modifying factors.
Associated signs and symptoms.

What are the four components of a patient history?

There are four elements of the patient history: chief complaint, history of present illness (HPI), review of systems (ROS), and past, family, and/or social history (PFSH).

What are the three key E & M components?

The three key components when selecting the appropriate level of E/M services provided are history, examination, and medical decision making. Visits that consist predominately of counseling and/or coordination of care are an exception to this rule.

What is the difference between the 1995 and 1997 guidelines?

Applying guidelines

For example, the 1997 guidelines allow consideration of chronic or inactive conditions in the review of systems and history, whereas the 1995 guidelines only count comorbidities.

How is MDM level calculated?

Each of the three MDM areas should be scored. The level is determined by selecting the highest two of the three distinct areas.

There are four levels of MDM to support the five ED E/M codes:

Straight forward (99281)
Low (99282)
Moderate (99283 and 99284)
High (99285)