Don’t look past history when choosing E/M levels

Why This Topic Matters

Accurate E/M coding depends on complete, well-structured documentation, and the history portion can materially affect the assigned level. Understanding the required components helps coding professionals evaluate chart support and promote consistency in reporting.

Article Sections

1. Introduction

   Introduces the role of history, exam, and medical decision-making in E/M level selection and notes the CMS guideline framework referenced in the article.

2. History

   Explains the history portion of E/M documentation and sets up the individual history components discussed in the subsections that follow.

3. Chief complaint (CC)

   Describes the purpose of the chief complaint and the type of documentation expected for this history element.

4. History of present illness (HPI)

   Covers the HPI as a chronological account of the presenting problem and discusses how it is categorized for documentation purposes.

5. Review of systems (ROS)

   Summarizes the review of systems as a structured part of the history and outlines the broad levels used to characterize it.

6. Past, family, and social history (PFSH)

   Reviews the PFSH portion of history and its three broad elements, along with the general categories used to assess completeness.

7. Determining overall history level

   Explains how the history components are combined to determine the overall level of history for E/M coding.