Codes and Documentation for Evaluation and Management Services

Step 3: Review the Service Descriptors and the Requirements for the Key Components of the Selected E/M Service

Almost every category or subcategory of E/M service lists the required level of history, examination, or medical decision making for that particular code.

For example, for E/M code 99223 the service descriptor is “Initial hospital care, per day, for the evaluation and management of a patient, which requires these three key components” and the code requires 

• Comprehensive history 

• Comprehensive examination 

• Medical decision making of high complexity 

Step 4: Determine the Extent of Work Required in Obtaining the History

The extent of the history obtained is driven by clinical judgment and the nature of the presenting problem. Four levels of work are associated with history taking. They range from the simplest to the most complete and include the components listed in the sections that follow

The elements required for each type of history are depicted in Table 4–2. Note that each history type requires more information as you read down the left-hand column. For example, a problem-focused history requires the documentation of the chief complaint (CC) and a brief history of present illness (HPI), and a detailed history requires the documentation of a CC, an extended HPI, an extended review of systems (ROS), and a pertinent past, family, and/or social history (PFSH).

The extent of information gathered for a history is dependent on clinical judgment and the nature of the presenting problem. Documentation of patient history includes some or all of the following elements.

A. CHIEF COMPLAINT (CC) 

The chief complaint is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. It is usually stated in the patient’s own words. For example, “I am anxious, feel depressed, and am tired all the time.”

B. HISTORY OF PRESENT ILLNESS (HPI)

The history of present illness is a chronological description of the development of the patient’s present illness from the first sign and/or symptom or from the previous encounter to the present. HPI elements are:

• Location (e.g., feeling depressed) 

• Quality (e.g., hopeless, helpless, worried) 

• Severity (e.g., 8 on a scale of 1 to 10) 

• Duration (e.g., it started 2 weeks ago)

• Timing (e.g., worse in the morning) 

• Context (e.g., fired from job) 

• Modifying factors (e.g., feels better with people around) 

• Associated signs and symptoms (e.g., loss of appetite, loss of weight, loss of sexual interest) 

There are two types of HPIs, brief and extended:

1. Brief includes documentation of one to three HPI elements. In the following example, three HPI elements—location, severity, and duration—are documented: 

• CC: Patient complains of depression.

• Brief HPI: Patient complains of feeling severely depressed for the past 2 weeks.

2. Extended includes documentation of at least four HPI elements or the status of at least three chronic or inactive conditions. In the following example, five HPI elements—location, severity, duration, context, and modifying factors—are documented:

• CC: Patient complains of depression. 

• Extended HPI: Patient complains of feelings of depression for the past 2 weeks. Lost his job 3 weeks ago. Is worried about finances. Trouble sleeping, loss of appetite, and loss of sexual interest. Rates depressive feelings as 8/10.