E/M Coding Alert - 2010 Issue 12
Reader questions: 99202-99205 Take PFSH to a New Level
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Article Overview
This premium article addresses a reader question about documentation of past, family, and social history in the context of new patient evaluation and management services. It is aimed at coders, auditors, compliance staff, and clinicians who work with office visit documentation standards and want to understand the broad history-component requirements discussed in CPT and Medicare guidance.
Why This Topic Matters
Accurate history documentation affects E/M level selection, compliance review, and office workflow. The article helps readers understand the general documentation expectations that can influence coding for new patient visits and related audit readiness.
Article Sections
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Question
Introduces a reader scenario about office documentation for a new patient visit and the history elements recorded in the chart.
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Answer
Provides a high-level response about how the documented history components fit into broader E/M history categories.
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How it works
Summarizes the levels of history discussed in the article and places them in the context of new patient office visit coding.
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Pertinent
Discusses the general meaning of a pertinent history review and notes its relationship to documentation guidance.
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Complete
Explains the broader concept of complete history documentation and distinguishes between new and established patient visit contexts.
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Remember
Offers a compliance-oriented reminder about reviewing documentation practices with physicians when required history elements are frequently omitted.
What You Will Learn
- How the article frames past, family, and social history in E/M documentation
- The difference between general history levels discussed in the article
- How the topic relates to new patient office visit documentation
- Why documentation review and compliance education may be relevant
Who Should Read This
- Medical coders
- Coding auditors
- Compliance staff
- Physicians
- Surgeons
- Practice managers
Codes Discussed
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