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Correct Answer: comprehensive.
in e/m (evaluation and management) coding within the healthcare industry, the determination of the level of history is crucial for appropriate billing and documentation of a patient encounter. the levels of history are graded from least to most detailed: problem-focused, expanded problem focused, detailed, and comprehensive. each level has specific requirements that must be met in the medical documentation to qualify as that level of history.
the highest and most descriptive level of history in e/m coding is the comprehensive history. this level requires the most extensive documentation and is essential for encounters that involve more complex or severe medical scenarios. when a medical professional performs a comprehensive history, it indicates a thorough evaluation of the patient.
the components of a comprehensive history include a chief complaint (cc), an extended history of present illness (hpi), a review of systems (ros) that covers at least ten organ systems, and a complete history that incorporates past medical, family, and social history (pfsh). each of these elements must be documented in detail.
the chief complaint is a concise statement describing the symptom, problem, condition, diagnosis, or other factors that are the reason for the encounter, typically in the patient's words. the extended hpi should include a detailed description of the patient's current complaint, typically involving multiple elements such as the quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms.
for the review of systems, the healthcare provider must document at least ten systems reviewed beyond the system directly related to the problems identified in the hpi. this comprehensive review helps to identify other potential issues that might affect diagnosis and treatment.
lastly, a complete pfsh is required. this includes a thorough exploration of the patient's past medical history, a review of any familial diseases or conditions that might affect patient care, and an assessment of relevant social factors such as occupation, lifestyle, and health habits.
understanding and correctly applying the level of history in e/m coding is not just about ensuring appropriate reimbursement; it also significantly impacts patient care management. the comprehensive history is integral in forming a complete picture of the patient's health and plays a crucial role in planning effective treatment strategies.
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