Table 3
Minimum requirements for highest-level billing in a new patient (inpatient/outpatient)
| Sections | 1995 | 1997 |
| CC |
|
|
| HPI | Four elements or status update of three chronic conditions | Four elements or status update of three chronic conditions |
| PFSH | One element from all three categories | One element from all three categories |
| ROS | One element from least 10 of 14 systems | One element from least 10 of 14 systems |
| PE | One element from at least eight organ systems OR One complete single specialty system examination | At least two bullets in at least nine organ systems |
Always document why it is not possible to obtain information regarding a specific element of history or examination to receive credit for addressing that element, body area or organ system.
CC, chief complaint; HPI, history of present illness; PE, physical examination; PFSH, past, family, and/or social history; ROS, review of systems.