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Detailed History
 

 
The Detailed History is the second highest level of history and requires a chief complaint, an extended HPI (four HPI elements OR the status of three chronic or inactive problems - if using the 1997 E/M guidelines), plus TWO to NINE  ROS, plus at least ONE pertinent element of PFSH .

Example 

Level 4 office visit (99214) for a patient with hypertension and diabetes

CC : Follow-up hypertension and diabetes

Interval History : The patient’s hypertension is stable on current medications.  Diabetes, however, remains sub-optimally controlled with hgbA1c greater than 7.  There is also a history of osteoarthritis, which requires only intermittent Tylenol for symptomatic relief .

ROS   
General--Negative for fatigue, weight loss, anorexia
Cardiovascular--Negative for CP, orthopnea, PND
Endocrine--Negative for polyuria, polydipsia, cold intolerance

Pertinent PMH is positive for CAD, which has been quiescent

For this example, the extended HPI was constructed by commenting on the status of three chronic or inactive problems (hypertension, diabetes, OA).  The ROS described three systems, although technically only two systems are required.  This example utilized an element of PMH (CAD) to satisfy the requirement of one pertinent PFSH.  However, the examiner could just as easily have chosen to include an item from the social history (such as ongoing tobacco abuse) or family history (such as premature cardiovascular disease in first degree relatives) to satisfy the PFSH requirement.

Modified Detailed History
 
For a the following encounters, the requirement for an element of PFSH to qualify for a Detailed History is waived
        1. Subsequent Hospital Care (i.e. hospital progress notes)
        2. Follow-up Inpatient Consultations
        3. Subsequent Nursing Facility Care
For these encounters you can qualify for a Detailed History without having to include any elements of PFSH.   For example, a Detailed History for a level 3 hospital progress note (99233)  would require only a chief complaint, an extended HPI (four HPI elements OR the status of three chronic or inactive problems - if using the 1997 E/M guidelines), and  two to nine elements of  ROS.  You don't have to include any PFSH.
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Click to return to E/M University Home page, EM Coding Education