The levels of E/M services are based on four types of history (Problem Focused, Expanded Problem Focused, Detailed and Comprehensive). Each type of history includes some or all of the following elements:

  • Chief complaint (CC)
  • History of present illness (HPI)
  • Review of systems (ROS)
  • Past, family and/or social history (PFSH)

The extent of history of present illness, review of systems and past, family and/or social history that is obtained and documented is dependent upon clinical judgment and the nature of the presenting problem(s).

The chart below shows the progression of the elements required for each type of history. To qualify for a given type of history all three elements in the table must be met.

While documentation of the CC is required for all levels, the extent of information gathered for the remaining elements related to a patient’s history is dependent upon clinical judgment and the nature of the presenting problem.  

HPI
Brief  1 -  3
Extended >/= 4 or the status of 3 or more chronic/inactive conditions)
ROS
None
Problem Pertinent
Extended 2 – 9
Complete >/= 10
PFSH
None
None
Pertinent 1 – 2 (New or Comprehensive Patient)
Pertinent 1 (Established and Emergency Department Patient)
Complete 3 (New or Comprehensive Patient)
Complete 2-3 (Established Patient Established and Emergency Department Patient)
HISTORY TYPE
PROBLEM* FOCUSED
EXPANDED* PROBLEM FOCUSED
DETAILED*
COMPREHENSIVE*

*All three elements indicated in a specific column must be met

Chief Complaint (CC)
The CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return or other factor that is the reason for the encounter, usually stated in the patient's words.

Examples:

  • Chief Complaint: Osteoarthritis
  • CC: Sore throat
  • CC: Dizziness

History Of Present Illness (HPI)
The HPI is a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present. It includes the following elements:

  • Location
  • Quality
  • Severity
  • Duration
  • Timing
  • Context
  • Modifying factors
  • Associated signs and symptoms

Brief and extended HPIs are distinguished by the amount of detail needed to accurately characterize the clinical problem(s).

A brief HPI includes documentation of one to three HPI elements (for both 1995 and 1997 documentation guidelines).

Example: Patient complains of cough which started two days ago. Tried Robitussin but did not help.

  • Duration: 2 days
  • Modifying Factors: Robitussin

An extended HPI includes documentation for at least four HPI elements or the status of at least three chronic or inactive conditions (for both 1995 and 1997 guidelines). The status of at least three chronic or inactive conditions should be documented in the History component. It is typically in a sentence format; however the provider may list the chronic/inactive conditions along with the status.

Example based on four or more elements: Patient complains of chest pain, which began two hours ago. Occurs with minimal exertion. Rates pain a '9' on a scale of 1-10. The patient has never experienced anything like this previously.

  • Location: Chest
  • Duration: Two hours ago
  • Context: Occurs with minimal exertion
  • Severity: Rates pain a '9' on a scale of 1-10

Example based on the status of at least three chronic or inactive conditions:

  • Type II Diabetes, uncontrolled, BS 170
  • Hypertension, well controlled
  • Hyperlipidemia, stable on Lipitor

Review Of Systems (ROS)
A ROS is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced.

For purposes of ROS, the following systems are recognized:

  • Constitutional symptoms (e.g., fever, weight loss)
  • Eyes
  • Ears, Nose, Mouth, Throat
  • Cardiovascular
  • Respiratory
  • Gastrointestinal
  • Genitourinary
  • Musculoskeletal
  • Integumentary (skin and/or breast)
  • Neurological
  • Psychiatric
  • Endocrine
  • Hematologic/Lymphatic
  • Allergic/Immunologic

There are three types of ROS: problem pertinent, extended, and complete.

A problem pertinent ROS inquires about the system directly related to the problem identified in the HPI.
An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number (two to nine) of additional systems.

A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional (minimum of ten) organ systems. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented. Avoid using the following statements, '10 systems negative, 12 systems negative, etc.'

Past, Family and/or Social History (PFSH)
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)
  • Social history (an age appropriate review of past and current activities)

For certain categories of E/M services that include only an interval history, it is not necessary to record information about the PFSH. Those categories are subsequent hospital care and subsequent nursing facility care.

The two types of PFSH are: pertinent and complete.

A pertinent PFSH is a review of the history areas directly related to the problem(s) identified in the HPI.  The pertinent PFSH must document at least one item from any of the three history areas.

A complete PFSH is a review of two or all three of the areas, depending on the category of E/M service. A complete PFSH requires a review of all three history areas for services that, by their nature, include a comprehensive assessment or reassessment of the patient. A review of two history areas is sufficient for other services.

At least one specific item from two of the three history areas must be documented for a complete PFSH for the following categories of E/M services:

  • Office or other outpatient services, established patient
  • Emergency department
  • Domiciliary care, established patient
  • Subsequent NF care
  • Home care, established patient

At least one specific item from each of the history areas must be documented for the following categories of E/M services:

  • Office or other outpatient services, new patient
  • Hospital observation services
  • Hospital inpatient services, initial care
  • Comprehensive NF assessments
  • Domiciliary care, new patient
  • Home care, new patient

Documentation Reminders/Frequently Asked Questions (FAQs)

  • The CC, ROS and PFSH may be listed as separate elements of history or they may be included in the description of the history of the present illness
  • A ROS and/or a PFSH obtained during an earlier encounter do not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:
    • Describing any new ROS and/or PFSH information or noting there has been no change in the information
    • Noting the date and location of the earlier ROS and/or PFSH
  • If the physician is unable to obtain a history from the patient or other source, the documentation must clearly reflect:
    • The components that were unobtainable (HPI, ROS and/or PFSH)
    • Circumstances that preclude obtaining the HPI, ROS, and PFSH (dementia, sedated on a vent, etc.). When using ‘poor’ historian the documentation must support why (e.g. dementia).
    • Attempt to obtain from other resources:
      • A family member, spouse, nurse etc. was not present or was unable to provide additional information
      • The medical record (chart, ambulance run sheet, etc.) did not contain the information needed

If patient or family can provide information at a later time, the provider may add an addendum containing this information. The provider may add an addendum containing the additional information.

  • Documentation cannot be used twice under the History Component. This is referred to as 'double dipping.' Example: Allergies may be used under the ROS (Allergic/Immunologic) or under past history.
  • The ROS and PFSH may be recorded on a form completed by the patient
    • The provider must review the documentation
    • There must be notation supplementing or confirming the information
    • Recommend signing the form completed by the patient
  • If a physician documents negative findings for the HPI, for example (subsequent hospital visit for CHF), provider states, 'Denies any SOB,' he/she may use this information under 'Associated Signs/Symptoms.'
  • A patient may present with more than one complaint/sign/symptom
    • May use the most descriptive under the HPI
    • Additional information may be used under ROS
  • A ROS is a review of 'symptoms' not diagnoses such as 'denies CHF or denies Diabetes'
  • Ancillary staff may perform/document the:
    • Review of systems (ROS)
    • Past, family and social history (PFSH)
    • Vital signs

These three areas must be reviewed by the physician or non-physician practitioner (NPP) who must write a statement that it is reviewed and correct or add to it.

Only the physician or NPP that is conducting the E/M service can perform the history of present illness (HPI). This is considered physician work and not relegated to ancillary staff. The exam and medical decision making are also considered physician work and not relegated to ancillary staff. In certain instances, an office or emergency room triage nurse may document pertinent information regarding the chief complaint (CC)/HPI, but this information should be treated as preliminary information. The physician providing this E/M service must consider this information preliminary and needs to document that he or she explored the HPI in more detail.

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