E/M Weekly Tip: History Component - Interval History

For certain categories of E/M services that include only an interval history, it is not necessary to record information about the past, family and social history (PFSH). Those categories are subsequent hospital care and subsequent nursing facility care. In order to receive "credit" for an interval history the provider must provide an update on the status of the patient from the last encounter. It may be a simple statement like "no complaint of sob," "complains of chest pain” or "pt. feels better today."

Reminder: The chief complaint is still required.

Reference: CMS 1995 & 1997 E/M Guidelines