Interval History

by  Codapedia
December 3rd, 2015

By: Codapedia Editor (Feb/09/2009) 

In the CPT® book, some E/M codes are described as requiring an "expanded problem focused history" or a "detailed history."  Others require "an expanded problem focused interval" history or a "detailed interval history."  What's the difference?

Past medical, family and social history.  These three are not required for an interval history.  (Of course, they are never required for an expanded problem focused history, but the CPT® book still makes the distinction.)

Subsequent hospital visits and subsequent nursing facility visits are those that are defined with the term interval history.  In practical terms, it means that past medical, family and social history are never required for these categories of services.

Where is the documentation for that statement? First, looking at the CPT® definitions for those categories of codes, all are defined as requiring an interval history.  Second, go back to the Documentation Guidelines themselves and see the definition of an interval history.  This illustrates something important about the Guidelines and E/M codes.  In order to review E/M records, an auditor needs three things:

References:

Interval History. (2015, December 3). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/interval-history-28002.html

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