Table I History (Hx) Component: The overall level of history is determined based upon all – three of the history elements (HPI, ROS and PMFSW) being met at the same level or higher. Requirements Requirements for an Extended HISTORY for a Problem Problem Requirements for Requirements for a ELEMENTS Focused (PF) Focused (EPF) a Detailed (D) Comprehensive (C) Level Level Level Extended 4+ Extended 4+ elements elements (Initial (Initial visits visits require(s) an require(s) an injury injury causation causation statement statement and/or A. History of and/or an objective an objective Present functional goal Brief 1-3 elements Brief 1-3 elements functional goal Illness/Injury treatment plan. treatment plan. Follow-up visits (HPI) Follow-up visits require objective require objective functional functional gains/losses, ADLs, gains/losses, ADLs, etc.) etc.) Problem B. Review of pertinent-limited 2-9 body parts or Systems (ROS) None Complete 10+ to injured body body systems (not required for part established patient visits) C. Past Medical, Family and Pertinent 1 of 4 2 or more of the 4 None None Social/Work types of histories types of histories History (PMFSH) A. HPI Elements represent the injured worker relaying their condition to the physician and should include the following: 1. Location (where?) 2. Quality (sharp, dull) 3. Severity (pain level 1-10 or pain diagram) 4. Duration (how long?)
Table I – History (Hx) Component: The overall level of history is determined based upon all three of the history elements (HPI, ROS and PMFSW) being met at the same level or higher. HISTORY ELEMENTS Requirements for a Problem Focused (PF) Level Requirements for an Extended Problem Focused (EPF) Level Requirements for a Detailed (D) Level Requirements for a Comprehensive (C) A. History of Present Illness/Injury (HPI) Brief 1-3 elements Brief 1-3 elements Extended 4+ elements (Initial visits require(s) an injury causation statement and/or an objective functional goal treatment plan. Follow-up visits require objective functional gains/losses, ADLs, etc.) Extended 4+ elements (Initial visits require(s) an injury causation statement and/or an objective functional goal treatment plan. Follow-up visits require objective functional gains/losses, ADLs, etc.) B. Review of Systems (ROS) (not required for established patient visits) None Problem pertinent-limited to injured body part 2-9 body parts or body systems Complete 10+ C. Past Medical, Family and Social/Work History (PMFSH) None None Pertinent 1 of 4 types of histories 2 or more of the 4 types of histories A. HPI Elements represent the injured worker relaying their condition to the physician and should include the following: 1. Location (where?) 2. Quality (sharp, dull) 3. Severity (pain level 1-10 or pain diagram) 4. Duration (how long?)
Rule_18_Exhibit_7_2017.docx