According to the American Medical Association’s CPT® book, a new patient is a patient who “has never received professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years.
There is an excellent chart in the front section of the CPT® book to help differentiate between a new patient and an established patient. If you have a question about whether the patient is new or established lo...
The guidelines go on to read, "The medical record should clearly reflect the chief complaint." This leaves physicians to ask the question, does the chief complaint need to be listed separately from the history of the present illness or the rest of the rest of the history?
The guidelines also say:
!DG: The CC, ROS and PFSH may be listed as separate elements of history, or theymay be included in the description of the history of the present illness.
That is, a physician or other healt...
Past medical, family and social history
When an Evaluation and Management service requires past medical, family and social history, (or one or two of those) here is what needs to be documented, and the rules around using one that is previously documented.
Past medical history includes the patient's chronic illnesses, previous illnesses, injuries and surgeries, medications and past treatment.
Social history includes smoking, drug, and alcohol use, employment, and living situation.
Family history includes a review of illness/health s...