Coding Corner Answer

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This history level is headed in the direction of a level-four visit if the documentation for either the examination or medical decision making is strong enough. Remember, it also could drop down to a level-three visit if the documentation is not strong enough in the two other sections of the evaluation and management visit.

Getting to This Answer: The history of present illness has six elements:

• Modifying factors: The patient is on celecoxib, methotrexate, folic acid, and lansoprazole.
• Severity: The patient reports pain to be moderate.
• Location: The pain is in her wrists and finger joints.
• Timing: She reports generalized morning stiffness for one to three hours.
• Associated signs and symptoms: The patient fatigues easily.
• Duration: The patient has swelling and stiffness every day.

The review of systems has seven elements:

• Gastrointestinal: The patient denies dyspepsia or abdominal complaints.
• Hematologic/Immunologic: She denies fever, Raynaud’s phenomenon, and hematochezia.
• Cardiovascular: The patient denies chest pain.
• Respiratory: She denies dyspnea and cough.
• Ears, nose, mouth, and throat: The patient denies oral ulcers.
• Integumentary: The patient denies rashes.
• Psychological: She denies insomnia and depression.

Her family and social history has two elements:

• Past medical history: The patient has a history of GERD.
• Social history: She is married with two children.

This encounter is an established-patient outpatient visit. This history level is detailed:

• The history of present illness is extended because there were six elements.
• The review of systems was extended because there were seven elements.
• The past family and social history was extended because there were two elements.