tci General Surgery Coding Alert - 2020 Issue Q3

Reader Questions: Focus Comprehensive History Requirements

Question: I have a surgeon’s note for an office visit that includes a chief complaint, an extended history of present illness (HPI), a problem-pertinent review of systems (ROS), and a complete past, family, and social history (PFSH). Is that enough information for a comprehensive history? SuperCoder Subscriber Answer: For a comprehensive history, you need to meet or exceed the following four elements: a chief complaint, an extended HPI, a complete ROS, and a complete PFSH. Your scenario matches three of those elements (chief complaint, extended HPI, and complete PFSH), but the problem-pertinent ROS you have documented is lower...

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