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:
- The CPT® book, which defines the level of history, exam and MDM for each code, and whether 2 of 3 or 3 of 3 components are required
- A copy of the Documentation Guidelines, which define what an expanded problem focused history or exam is, and all of the levels of history, exam and MDM cited in the CPT® book
- A valid audit tool