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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?
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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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