In preventive medicine and well-child services, it is common to ask to what level of history must the documentation support the service. Using Current Procedural Terminology (CPT®), the short answer is that the “comprehensive” nature of the preventive medicine service codes 99381–99397 reflect age- and gender-appropriate history and examination. The more comprehensive answer involves what exactly is considered age and gender appropriate.

The history components as defined in CPT and Documentation Guidelines for Evaluation and Management Services include a chief complaint (CC); past, family, or social history (PFSH); history of present illness (HPI); and review of systems (ROS). For evaluation and management (E/M) services that are defined by 3 key components (history, examination, and medical decision-making), certain numbers of each element of history are used to define level of history. This is not true for preventive medicine services. Unless an abnormality is encountered, the preventive medicine service...

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