This article relates to the 1995/1997 documentation guidelines, and not to office/outpatient codes 99202–99215 in 2021.
E/M codes are defined by the level of key components performed and documented. History is the first component.
Used to describe the E/M codes in the medicine section of the CPT® book.
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:
- modifying factors
- associated signs and symptoms.
- 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:
- Ears/nose/mouth/throat (these four are all one system)
- Hematologic/lymphatic (one system)
- Allergic/Immunologic (one system).
- Past medical, family and social history – PFSH describes:
- The patient’s medical history, including past surgeries, medical problems, allergies and medications,
- Their social history including work, living situation, alcohol, drug and tobacco use and,
- Family history, genetic illnesses, health status and diseases of family members.
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