Past, Family, and Social History:
Past History:
Patient’s past experiences with illnesses, operations, injuries, treatments, medications, or allergies relevant to the condition being treated. (All medications and allergies are relevant.)
Family History:
Diseases which are hereditary, or put the patient at risk. .
Social History:
Past or current activities that are appropriate for patient (i.e. smoking – active or passive, drug use, alcohol use).
Coding Requirements:
New Patients
Level 99202 require none
Level 99203 require none
Level 99204 require at least 1
Level 99205 require at least 3
Established Patients
Level 99212 requires none
Level 99213 requires none
Level 99214 requires at least 1
Level 99215 requires at least 2
If the patient is unable to provide this information, document this fact in the chart and the reason. You will then be able to use the maximum number available.
