In the CPT® book, some E/M codes are described as requiring an "expanded problem focused history" or a "detailed history." Others require "an expanded problem focused interval" history or a "detailed interval history." What's the difference?
Past medical, family and social history. These three are not required for an interval history. (Of course, they are never required for an expanded problem focused history, but the CPT® book still makes the distinction.)
Subsequent hospital visits and subsequent nursing facility visits are those that are defined with the term interval history. In practical terms, it means that past medical, family and social history are never required for these categories of services.
Where is the documentation for that statement? First, looking at the CPT® definitions for those categories of codes, all are defined as requiring an interval history. Second, go back to the Documentation Guidelines themselves and see the definition of an interval history. This illustrates something important about the Guidelines and E/M codes. In order to review E/M records, an auditor needs three things:
The CPT® book, which defines the level of history, exam and MDM for each code, and whether 2 of 3 or 3 of 3 components are required
A copy of the Documentation Guidelines, which define what an expanded problem focused history or exam is, and all of the levels of history, exam and MDM cited in the CPT® book
A valid audit tool
If you have questions or comments about this article please contact us. Comments that provide additional related information may be added here by our Editors.
Now is the time to comment on a proposal to cover acupuncture for chronic low back pain. This comment period is the part of the HHS response to the opioid crisis. You only have until August 14th to officially comment.
A recent article by Modern Medicine cited a report by Becker’s Hospital Review which stated that it costs approximately $118 per claim to resolve a claim denial. Granted, these were hospital claims, but the process is essentially the same for outpatient services. In fact, you could say it is...
It is in regards to the Initial and Subsequent 7th digit (A and D) for sprains and strains. Recently, I have been told that I should continue with the A digit until the patient has reached Maximum Medical Improvement (MMI) and then switch over to the D place holder. Is ...
ICD-10-CM codes represent the first line of defense when it comes to medical necessity. Correctly chosen diagnosis codes support the reason for the visit as well as the level of the E/M services provided. The issue of medical necessity is one of definitions and communication. What is obvious to the ...
Are there scenarios in which it is acceptable to put the DC's NPI in box 24j for massage services?
While the answer to this is yes, it is essential to understand that there are very limited scenarios. In most cases, Item Number 24J is only for the NPI of the individual ...
Low level laser therapy (LLLT), also known as cold laser therapy, is a form of phototherapy which uses a device that produces laser beam wavelengths, typically between 600 and 1000 nm and watts from 5–500 milliwatts (mW). It is often used to treat the following:
Inflammatory conditions (e.g., Rheumatoid Arthritis, Carpal ...