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History | Documentation Guidelines for E/M Services

Definition

History is one of the three key components (history, exam, and medical decision making) of Evaluation and Management Services. You can read about exam here and MDM here.

Explanation

E/M codes are defined by the level of key components performed and documented. History is the first component.

What makes up the history | CC, ROS, HPI, PFSH

  • The chief complaint – CC is a concise statement describing the reason for the encounter.
  • History of the present illness  – HPI is composed of adjectives that describe the patient’s condition. The guidelines define eight of these:
    1. location
    2. quality
    3. severity
    4. duration
    5. timing
    6. context
    7. modifying factors
    8. associated signs and symptoms.

The 1997 guidelines allow providers to document the status of three chronic diseases in place of the four HPI elements. The CMS reference guide to the 1997 guidelines can be found here.

  • Review of systems – ROS is an inventory of positive and negative systems that describe the patient’s condition. These systems are defined by the guidelines as:
    1. constitutional
    2. Eyes
    3. Ears/nose/mouth/throat (these four are all one system)
    4. Cardiovascular,
    5. Respiratory
    6. GI
    7. GU
    8. Musculoskeletal
    9. Integumentary
    10. Neurological
    11. Psychiatric
    12. Endocrine
    13. Hematologic/lymphatic (one system)
    14. Allergic/Immunologic (one system).
  • Past medical, family and social history – PFSH describes:
    1. The patient’s medical history, including past surgeries, medical problems, allergies and medications,
    2. Their social history including work, living situation, alcohol, drug and tobacco use and,
    3. Family history, genetic illnesses, health status and diseases of family members.
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Accurate at time of posting: July 5, 2017
by Betsy Nicoletti

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Our mission is to provide accurate, comprehensive, up-to-date coding answers, allowing medical practices to increase revenue, decrease coding denials and reduce compliance risk. That's what coding knowledge can do.

In 1988, CodingIntel.com founder Betsy Nicoletti started a Medical Services Organization for a rural hospital, supporting physician practice. She has been a self-employed consultant since 1998. She estimates that in the last 20 years her audience members number over 22,100 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 40,000 medical notes. She knows what questions need answers and developed this resource to answer those questions. For more about Betsy visit www.betsynicoletti.com.

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