History | Documentation Guidelines for E/M Services

ARCHIVE

The 1995/1997 Documentation Guidelines are gone beginning 1-1-2023. (Ding dong….) However, we will still need to use them when auditing notes from before 2023.

This article does not apply to services performed after 1-1-2023.

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.

Codes

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:
  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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