History

The history is one of the three key components of E/M documentation.  The history is designed to act as a narrative which provides information about the clinical problems or symptoms being addressed during the encounter.  The history is composed of four building blocks:

1. Chief Complaint

2. History of Present Illness

3. Review of Systems

4. Past Medical, Family and Social History

 Levels of History

  The E/M guidelines recognize 4 “levels of history” of incrementally increasing complexity and detail:  

1. Problem Focused

2. Expanded Problem Focused

3. Detailed

4. Comprehensive

All levels of history require a chief complaint and some form of HPI (or Interval History), but not all levels of history require an ROS or PFSH.  The following table shows the individual requirements for each level of history.

Coding Tip: With the notable exception of the rules for completing an extended HPI, the 1995 and 1997 E/M guidelines are identical when it comes to the rules defining the various levels of history.

Coding Tip: The Chief Complaint may be recorded separately or may be documented within the HPI.