The most complex of the history types; the physician documents the chief complaint, obtains an extended history of the present problem, does a complete review of systems, and obtains a complete PFSH.
What is comprehensive history
100
A disease, condition, illness, injury, symptom, sign, finding, complaint, or other reason for the encounter, with or without a diagnosis being established at the time of the encounter.
What is presenting problem
100
The care of critically ill patients in medical emergencies that requires the constant attendance of the physician.
What is critical care
200
HPI
What is History of Present illness
200
MDM
What is Medical Decision Making
200
Medical decision making complexity level requiring minimal diagnosis and management options, minimal or none for the amount and complexity of data to be reviewed.
What is straightforward decision making
200
In the CPT manual; provide specific instructions about coding for each section.
What is guidelines
200
Those services rendered by a physician whose opinion or advice is requested by another physician or agency concerning the evaluation and/or treatment of a patient.
What is consultation
300
ROS
What is Review of Systems
300
The physician focuses on the chief complaint and a brief history of the present problem of a patient.
What is Problem focused history
300
Medical decision making complexity level requiring limited number of diagnoses and management options, limited data to be reviewed, and low risk to the patient of complications or death if untreated.
What is low complexity
300
Procedures that are considered unusual, experimental, or new and do not have a specific code number assigned.
What is unlisted procedures
300
Counseling, coordination of care, nature of the presenting problem, and time of an E/M service.
What is contributing factors
400
PFSH
What is Past, Family, and/or Social History
400
The physician focuses on a chief complaint, obtains a brief history of the present problem, and also performs a problem pertinent review of systems.
What is Expanded problem focus history
400
Medical decision making complexity level requiring multiple diagnoses and management options, moderate amount of complexity of data to be reviewed, and moderate risk to the patient of complications or death if untreated.
What is moderate complexity
400
Patient who has NOT received any professional services from the physician or another physician of the same specialty in the same group within the past 3 years.
What is new pt
400
Status used for the classification of a patient who does not have an illness severe enough to meet acute inpatient criteria, but does require hospitalization for a short period of time.
What is observation
500
BA
What is Body Areas
500
The physician focuses on a chief complaint, obtains an extended history of the present problem, an extended review of systems, and a pertinent PFSH.
What is Detailed History
500
Medical decision making complexity level requiring extensive diagnoses and management options, extensive amount and complexity of data to be reviewed, and high risk to the patient of complications or death if the problem is untreated.
What is high complexity
500
Affecting the entire body.
What is systemic
500
Patient who has received professional services from the physician or another physician of the same specialty in the same group within the past 3 years.