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Expanded Problem
Focused History |
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The Expanded Problem Focused History is the second lowest level of history. This history requires a chief complaint, a brief HPI (containing one to three HPI elements), plus one ROS. No PFSH is required.
Example
Level 3 office visit (99213) for a patient with allergic rhinitis
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CC : Follow-up for allergic rhinitis .
Interval History: The patient’s nasal congestion has significantly improved with steroid nasal spray and is now described as “mild” in severity.
ROS is negative for cough, hoarseness, or shortness of breath.
E/M University Coding Tip : Most physicians routinely over-document the history for the level 3 office visit. This example illustrates that an Expanded Problem Focused History does not require a lot of information. In this case, 2 HPI elements were used - location and severity. The ROS required review of only one system. In this case the respiratory system was reviewed. |
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