Surgeons as Educators A Guide for Academic Development and Teaching Excellence

426

HistoryPE Decision MakingMedical

Fig. 23.1 The three pillars
of billing

HISTORY

CC

Exam

LocationConstitutional Past Medical

Family

Social

Eyes

Lowest Level Determines Overall Level

ENTM

Respiratory

GI

GU

MS

Integument

Endocrine

CV

Hemat/Lymph

Allerg/Immun

Psychologic

Quality

Severity

Timing

Duration

Context

Mod Factors

Assoc. Sign/Sx

Not billable

without this

CONSULTS AND

NEW PATIENTS

ESTAB. PATIENTS

Level 1

CC Must be documented on every level of exam

Must be documented on every level of exam

HPI 1-3 items 1-3 items

1-3 1-3 4+ 4+

4+ items 4+ items 4+ items

Pertinent

Pertinent

2-9

1-2

1 2-3

33

10+

2-9 10+

ROS 10+

PFSH

CC

HPI

ROS

PFSH

Level 2 Level 3 Level 4 Level 5

Level 1 Level 2 Level 3 Level 4 Level 5

HPI ROS PSFH

Fig. 23.2 History billing rules

T.S. Köhler