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.

Problem Focused History

Brief HPI

The Problem Focused History is the lowest and least descriptive level of history.   This history requires only a chief complaint and a Brief HPI (which requires one to three HPI elements).  No ROS or PFSH are required. 

Example: Level 1 hospital progress note (99231) for a patient with nephrolithiasis          

CC: Follow-up nephrolithiasis          

Interval History: The patient’s left flank pain has resolved.

It may be hard to believe, but that is all that is required for a Problem Focused History for a level 1 hospital progress note.  Notice that a chief complaint is clearly stated and only one HPI element (location) is utilized.

Expanded Problem Focused History

The Expanded Problem Focused History is the second lowest level of history.  This history requires a chief complaint, a brief HPI (containing one to three HPI elements), plus one ROS.  No PFSH is required.

Example: Level 3 office visit (99213) for a patient with allergic rhinitis . 

CC : Follow-up for allergic rhinitis .

Interval History: The patient’s nasal congestion has significantly improved with steroid nasal spray and is now described as “mild” in severity.

ROS is negative for cough, hoarseness, or shortness of breath.

Coding Tip : Most physicians routinely over-document the history for the level 3 office visit.  This example illustrates that an Expanded Problem Focused History does not require a lot of information.   In this case 2 HPI elements were used: location and severity.   The ROS required review of only one system.  In this case the respiratory system was reviewed.

The Detailed History

This is the second highest level of history and requires a chief complaint, an extended HPI (four HPI elements OR the status of three chronic or inactive problems - if using the 1997 E/M guidelines), plus TWO to NINE  ROS, plus at least ONE pertinent element of PFSH .

Example: Level 4 office visit (99214) for a patient with hypertension and diabetes

CC : Follow-up hypertension and diabetes

Interval History : The patient’s hypertension is stable on current medications.  Diabetes, however, remains sub-optimally controlled with hgbA1c greater than 7.  There is also a history of osteoarthritis, which requires only intermittent Tylenol for symptomatic relief.

ROS   
General--Negative for fatigue, weight loss, anorexia

Cardiovascular--Negative for CP, orthopnea, PND

Endocrine--Negative for polyuria, polydipsia, cold intolerance

Pertinent PMH is positive for CAD, which has been quiescent

For this example, the extended HPI was constructed by commenting on the status of three chronic or inactive problems (hypertension, diabetes, OA).  The ROS described three systems, although technically only two systems are required.  This example utilized an element of PMH (CAD) to satisfy the requirement of one pertinent PFSH.  However, the examiner could just as easily have chosen to include an item from the social history (such as ongoing tobacco abuse) or family history (such as premature cardiovascular disease in first degree relatives) to satisfy the PFSH requirement.

Modified Detailed History

For a the following encounters, the requirement for an element of PFSH to qualify for a Detailed History is waived

1. Subsequent Hospital Care (i.e. hospital progress notes)

2. Follow-up Inpatient Consultations

3. Subsequent Nursing Facility Care

For these encounters you can qualify for a Detailed History without having to include any elements of PFSH.   For example, a Detailed History for a level 3 hospital progress note (99233)  would require only a chief complaint, an extended HPI (four HPI elements OR the status of three chronic or inactive problems - if using the 1997 E/M guidelines), and  two to nine elements of ROS.  You don't have to include any PFSH.

Comprehensive History

The Comprehensive History is the highest level of history and requires a chief complaint, an extended HPI (four HPI elements OR the status of three chronic or inactive problems - if using the 1997 E/M guidelines), plus a 10 system ROS, plus a Complete PFSH .

Example: Level 3 H&P for a patient with chest pain

CC : Chest pain

HPI : The patient is a 65 year old male who developed sudden onset of chest pain, which began early this morning.  The pain is described as “crushing” and is rated nine out of 10 in terms of intensity .  

PMH is remarkable for GERD and hypertension

FH : Mother died at 78 of breast cancer; Father at 75 of CVA.  No history of premature cardiovascular disease in first degree relatives.

SH : Negative for tobacco abuse; consumes moderate alcohol; married for 39 years

ROS   
Constitutional--Negative for fevers, chills, fatigue

Cardiovascular--Negative for orthopnea, PND, positive for intermittent lower extremity edema
Gastrointestinal--Positive for nausea without vomiting; negative for diarrhea, abdominal pain
Pulmonary--Positive for intermittent dyspnea on exertion, negative for cough or hemoptysis  
All other systems reviewed and are negative  

This example illustrates the fact that the volume of documentation does not necessarily need to be excessive in order to qualify for a Comprehensive History.  The information included is useful and clinically relevant, but not obsessively detailed.  Note that ROS has been abbreviated by using the legal shortcut, “All other systems reviewed and are negative.”