History of Present Illness

 Severity Severity –moderate chest pain 6 out of moderate moderate chest pain, 6 out of 10 

 Duration-10 minutes, for a week 10 minutes, for a week 

 Modifying Factors–worse with exertion, worse with exertion, unrelieved by Tylenol 26 unrelieved by Tylenol 

 Associated Signs and Symptoms diaphoresis, fever, vomiting

 HPI flushes out the chief complaint in greater detail 

 There are two types of HPI identified for the purpose of coding 

 A brief HPI consists of HPI consists of 1-3 elements elements (99281-99283) 

 An extended HPI consists of at least HPI consists of at least 4 elements elements (99284-99285)

HPI Examples

 Brief- 32 year old male with 32 year old male with left shoulder left shoulder injury, occurred 4 hours ago

 Extended Extended-45 year old female with 45 year old female with left sided, sharp chest pain for 30 minutes with left arm numbness and diaphoresis 28 with left arm numbness numbness and diaphoresis  The pain is worse with exertion

Multiple Modifying Elements

Child with Chief Complaint of fever: Child with Chief Complaint Complaint of fever: 4 hours 4 hours of fever, with of fever, with moderate vomiting moderate vomiting, diaphoresis that is worse at night diaphoresis that is worse at night, right lower quadrant abdominal pain lower quadrant abdominal pain, unrelieved unrelieved by Tylenol

Level IV: General Comments

 Urgent Urgent Tx of condition of condition 

 Multiple diagnostic studies 

 Special studies alone (CT, MRI,US) 

 ED Interventions: 

 Nebs 21 

 Parenteral Parenteral medications medications 

 Usually not admitted 

Level V: General Comments 

 Many Admissions Frequently Involve: 

 Prolonged services in ED 

 Special Studies with other tests Special Studies with other tests-(CT/MRI/US) (CT/MRI/US) 

 Multiple reassessments 

 Interpretations of EKG or x Interpretations of EKG or x-rays 

 Old record review 

 Documented conversations

History 

The history portion of a patient The history history portion portion of a patient s patient s’ chart includes some or all of the following elements: 

DOCUMENTATION OF HISTORY

The levels of E/M services are based on four types of history (Problem Focused, Expanded Problem Focused, Detailed, and Comprehensive). Each type of history includes some or all of the following elements: 

• Chief complaint (CC); 
• History of present illness (HPI); 
• Review of systems (ROS); and 
• Past, family and/or social history (PFSH). 

The extent of history of present illness, review of systems, and past, family and/or social history that is obtained and documented is dependent upon clinical judgment and the nature of the presenting problem(s).

The chart below shows the progression of the elements required for each type of history. To qualify for a given type of history, all three elements in the table must be met. (A chief complaint is indicated at all levels.)  

History of Present Illness (HPI)	Review of Systems (ROS)	Past, Family, and/or Social History (PFSH)	Type of History
Brief	N/A	N/A	Problem Focused
Brief	Problem Pertinent	N/A	Expanded Problem Focused
Extended	Extended	Pertinent	Detailed
Extended	Complete	Complete	Comprehensive

DG: The CC, ROS and PFSH may be listed as separate elements of history, or they may be included in the description of the history of the present illness. 

DG: A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his/her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:

o describing any new ROS and/or PFSH information or noting there has been no change in the information; and 

o noting the date and location of the earlier ROS and/or PFSH

DG: The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others. 

DG: If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history.