The 1995/1997 Documentation Guidelines are gone beginning 1-1-2023. (Ding dong….) However, we will still need to use them when auditing notes from before 2023.
This article does not apply to services performed after 1-1-2023.
What does it mean when it says a code requires an “interval” history? This question related to the 1995/1997 Documentation Guidelines.
It is a history that does not require past medical, family, or social history.
An interval history is needed for a subsequent hospital visit or subsequent nursing facility visit. CPT® wording is, “an interval expanded focused history” or “an interval detailed history,” depending on the level of visit.
The definition of an interval history is found in the Documentation Guidelines, and here is the citation. First, the definition of PFSH, and then the definition of interval history.
The PFSH consists of a review of three areas:
- past history (the patient’s past experiences with illnesses, operations, injuries and treatments);
- family history (a review of medical events in the patient’s family, including diseases which may be hereditary or place the patient at risk); and
- social history (an age appropriate review of past and current activities).
For the categories of subsequent hospital care, follow-up inpatient consultations and subsequent nursing facility care, CPT® requires only an “interval” history. It is not necessary to record information about the PFSH.
Effectively that means for a detailed interval history, the requirement are: four HPI elements or the status of three chronic conditions and two systems from the review of systems. Past medical, family, and social history are not required.