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Expanded Problem
Focused History
 

 
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 ROSNo PFSH is required.


Example 

Level 3 office visit (99213) for a patient with allergic rhinitis

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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