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March 29, 2023

History | Documentation Guidelines for E/M Services

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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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Last revised February 2, 2023 - Betsy Nicoletti
Tags: behavioral health_E/M services, level of service_history, primary care_E/M services

CPT®️️ is a registered trademark of the American Medical Association. Copyright American Medical Association. All rights reserved.

2023 E/M reference sheets

These handy quick reference sheets included at-a-glance MDM requirements for office, hospital, nursing home and home and residence services. And, a bonus sheet with typical time for those code sets. Sign up for Betsy’s monthly newsletter to download these reference sheets and share them with your practitioners.

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2023 E/M guidelines for hospital, nursing facility, home and residence services | Webinar

Effective January 1, 2023, the AMA has revised the definitions and guidelines for hospital and other E/M services, including ED visits, nursing facility services, home services, and domiciliary care codes. Also, coding for prolonged care services gets another overhaul with revised codes and guidelines. Watch this webinar about all these changes.

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Our mission is to provide up-to-date, simplified, citation driven resources that empower our members to gain confidence and authority in their coding role.

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 28,400 at in person events and webinars. She has had 2,500 meetings with clinical providers and reviewed over 43,000 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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