Evaluation and Management History Component (Updated 11/17/06)

Home Provider Part B Publications

UPDATE: After consideration of provider comments and questions, WPS Medicare Policy staff is offering clarification of the information contained below. WPS recommends that providers follow the evaluation and management documentation guidelines as specified in CMS' Evaluation and Management Services Guide, Section I. C.3 for Review of Systems information. This guide can be found on CMS' Website at:
http://www.cms.hhs.gov/MLNProducts/downloads
/eval_mgmt_serv_guide.pdf adobe portable format258KB
CMS has made clear that this guide is offered as a reference tool and does not replace content found in the 1995 Documentation Guidelines for Evaluation and Management Services and the 1997 Documentation Guidelines for Evaluation and Management Services. During the review process, WPS Medicare will continue to apply whichever guideline is most advantageous to providers.

Are you looking for clarification concerning the appropriate documentation of the components of an Evaluation and Management (E/M) service? If so, then this first in a series of articles to be published in the Communiqué should prove helpful. This article specifically addresses documentation for the History portion of the visit. Like those to follow, we designed this article to clarify some of the complex issues related to the E/M codes.

One of the basic fundamentals in understanding the E/M coding intricacies is that there are three key components to be considered in selection of the appropriate level of service billed: History, Exam, and Medical Decision Making. Within the three key components are categories and subcategories that help determine the level of E/M services provided. The levels of E/M services recognize four types of history: Problem Focused, Expanded Problem Focused, Detailed, and Comprehensive.

The history component of an E/M service refers to subjective information obtained by the provider. This is not to be confused with objective, verifiable information obtained by direct examination of the patient by the provider. Each type of history includes some or all of the following elements:

  1. Chief Complaint (CC): The medical record should clearly reflect the chief complaint or the main reason for the visit. Notation of a chief complaint is needed for all levels of history documentation.


  2. History of Present Illness (HPI): A brief HPI includes one to three elements. An extended HPI includes four elements of the present illness or the status of at least three chronic or inactive conditions. Elements are comprised of the following:
    • Location
    • Quality
    • Severity
    • Duration
    • Timing
    • Context
    • Modifying factors
    • Associated signs and symptoms

    The HPI may only be obtained by the provider, and may not be obtained by ancillary staff.


  3. Review of Systems (ROS): A ROS is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced. The patient's responses related to the problem are documented. For an extended review of systems, the examiner inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems. Recognized systems include the following:
    • Constitutional symptoms
    • Eyes
    • Cardiovascular
    • Ears, nose, mouth and throat
    • Gastrointestinal
    • Respiratory
    • Musculoskeletal
    • Genitourinary
    • Neurological
    • Integumentary
    • Endocrine
    • Psychiatric
    • Allergic/immunologic
    • Hematologic/lymphatic

    For a complete ROS, the examiner inquires about the system(s) directly related to the problem(s) identified in the HPI, plus all additional body systems. At least 10 organ systems must be reviewed.


  4. Past, Family and/or Social History (PFSH): For certain categories of E/M services that include only an interval history, it is not necessary to record information about the PFSH. Those categories include Subsequent Hospital Care and Subsequent Nursing Facility Care. A pertinent PFSH will include at least one specific item from any of the three history areas. A complete PFSH for an established patient includes two of the three history areas. For a new patient or a consultation, documentation must include all three areas of history.

    It must be clear from the medical record documentation that the provider discussed the PFSH with the beneficiary.

    When Past, Family and/or Social History documentation has the terms "Non-contributory" or "negative," these are not considered appropriate documentation. Documentation of PFSH must include social and/or family history information, such as alcohol consumption, smoking history, occupation, or familial hereditary conditions.

    When the terms "non-contributory" or "negative" are used in PFSH documentation, the documentation might indicate "Past medical history is non-contributory" or "Social history is non-contributory." Such documentation would not indicate the provider had actually addressed the issues. It must be clear that the PFSH was discussed with the patient. To use the term "non-contributory" alone does not clearly indicate PFSH was addressed.

    The extent of the history of present illness, review of systems, and past family and/or social history that is documented is dependent upon the provider's clinical judgment and the patient's presenting problem(s). Documentation should support the level of service billed. The volume of documentation should not be the primary consideration for determining what specific level of service is billed.
Reference: Resident & New Physician Guide, 8th Edition
(located at http://www.cms.hhs.gov/MLNProducts/downloads
/physicianguide.pdf ) adobe portable format5MB