E/M Weekly Tip: History Component Types

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).

Read the articles below to learn more: