tci ED Coding & Reimbursement Alert - 2017 Issue 12

Reader Question: Know Which Observation Codes Require History

Question: Do we need to document a family history before assigning code 99220 or 99236 for comprehensive or high complexity observation services?   Supercoder.com Subscriber Answer: You are correct in that the CMS documentation guidelines say that comprehensive observation services, unlike ED E/M, require three of three past, family and social history elements for the highest level. Also, CPT® includes these elements in the definition of a comprehensive history, which is required for observation codes. Chief complaint; Extended history of present illness; Review of systems that is directly related to the problem(s) identified in the history of...

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