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History E&M Scoring

Charlene Posted Tue 03rd of March, 2020 09:51:15 AM
If extended HPI, problem pertinent ROS and complete PFS hx is documented, does this meet comprehensive history type? I know if all 3 components are of the same value, the value of the 3 determine the overall type, and if all 3 components are different values, the lowest component determines the overall type of history. If there are 2 components of the same level, do the 2 determine the type of history?
SuperCoder Answered Wed 04th of March, 2020 01:56:32 AM

Hi,

 

If extended HPI, problem pertinent ROS and complete PFS hx is documented, it will meet expanded problem focused (EPF) history type not comprehensive.

For comprehensive history, it should be extended HPI, complete ROS (10+ systems), and complete PFS.

If there are only two components of the same level, then it can also determine the type of history.

 

History selection depends on the following guidelines:

 

Problem Focused History

1. Chief Complaints

2. Brief HPI (1-3 elements)

 

Expanded Problem Focused (EPF) History

1. Chief Complaints

2. Brief HPI (1-3 elements)

3. Problem Pertinent ROS (1 system)

 

Detailed (DET) History

1. Chief Complaints

2. Extended HPI (4+ elements)

3. Extended ROS (2-9 systems)

4. Pertinent PFSH (1 category)

 

Comprehensive (COMP) History

1. Chief Complaints

2. Extended HPI (4+ elements)

3. Complete ROS (10+ systems)

4. Complete PFSH (3 category)

 

 

Hope this helps!

 

 

Thanks

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