History of Present Illness:
There are 8 factors that can be addressed:
1. Location – where is the problem on/in the body [LLL quadrant, throat, head]
2. Quality – a word that describes the problem [Sharp, dull, dry, wet, hot, cold, clammy, burning]
3. Severity – how is the problem rated [Mild, moderate, severe, excruciating, worsening Pain scale (4/10)]
4. Duration – how long do the symptoms last? [Constant, intermittent, seconds, minutes, hours, days, weeks, months]
5. Timing – when did symptoms begin? [One week ago, 3 hours ago]
6. Context – what was the patient doing that caused the symptoms? [Walking, standing, sitting, chewing, after eating]
7. Modifying Factors – what has been done to alleviate or worsen the symptoms? [OTCs, medications, rest, elevation, change in diet]
8. Associated Signs and Symptoms – conditions that go with the presenting problem [Headache, nausea, diarrhea, palpitations]
Coding Requirements:
Level 99202, 99212 require at least 1
Level 99203, 99213 require at least 1
Level 99204, 99214 require at least 4 (or status of at least 3 chronic health conditions)*
Level 99205, 99215 require at least 4 (or status of at least 3 chronic health conditions)*
If patient is unable to provide the history, document this and the reason they are unable to. This will allow you to consider the maximum number.
*The must be a rational for the reason of the status, such as lab work with specific information or symptom frequency.
