Review of Systems

 Allergic/Immunologic 

 Cardiovascular 

 Genitourinary 

 Hematolo Hematologic/Lymph. 

 Constitutional Symptoms 

 Ears, Nose, Mouth, Throat 

 Integumentary 

 Musculoskeletal 

 Neurological 

 Psychiatric

  Endocrine 

 Eye 

 Gastrointestinal 

 Psychiatric 

 Respiratory

 A problem pertinent ROS addresses 1 addresses 1 system (99282/99283) (99282/99283) 

 An extended ROS addresses 2 addresses 2-9 body systems (99284) 32 

 A complete ROS addresses addresses at least at least 10 organ systems (99285)

Past, Family, Social History (PFS)

 Past History  - A review of the patient's past A review of the patient's past experiences with illnesses, injuries, treatments experiences with illnesses, injuries, treatments, past hospitalizations, surgeries, medications, allergies, hospitalizations, hospitalizations, surgeries, surgeries, medications, medications, allergies, allergies, immunizations 

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

REVIEW OF SYSTEMS (ROS)

The review of systems is an inventory of body systems obtained by asking a series of questions in order to identify signs and/or symptoms that the patient may be experiencing or has experienced. The following systems are recognized:

• Constitutional (e.g., temperature, weight, height, blood pressure) 

• Eyes 

• Ears, nose, mouth, throat 

• Cardiovascular 

• Respiratory

• Gastrointestinal 

• Genitourinary 

• Musculoskeletal 

• Integumentary (skin and/or breast) 

• Neurological 

• Psychiatric

• Endocrine 

• Hematologic/Lymphatic 

• Allergic/Immunologic

There are three levels of ROS:

1. Problem pertinent, which inquires about the system directly related to the problem identified in the HPI. In the following example, one system—psychiatric—is reviewed:

• CC: Depression.

• ROS: Positive for appetite loss and weight loss of 5 pounds (gastrointestinal/constitutional).

2. Extended, which inquires about the system directly related to the problem(s) identified in the HPI and a limited number (two to nine) of additional systems. In the following example, two systems—constitutional and neurological— are reviewed:

• CC: Depression. 

• ROS: Patient reports a 5-lb weight loss over 3 weeks and problems sleeping, with early morning wakefulness

3. Complete, which inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional (minimum of 10) body systems. In the following example, 10 signs and symptoms are reviewed:

REVIEW OF SYSTEMS (ROS)

The review of systems is an inventory of body systems obtained by asking a series of questions in order to identify signs and/or symptoms that the patient may be experiencing or has experienced. The following systems are recognized:

• Constitutional (e.g., temperature, weight, height, blood pressure) 

• Eyes 

• Ears, nose, mouth, throat 

• Cardiovascular 

• Respiratory 

• Gastrointestinal

• Genitourinary

• Musculoskeletal 

• Integumentary (skin and/or breast) 

• Neurological

• Psychiatric 

• Endocrine 

• Hematologic/Lymphatic 

• Allergic/Immunologic

There are three levels of ROS:

1. Problem pertinent, which inquires about the system directly related to the problem identified in the HPI. In the following example, one system—psychiatric—is reviewed: 

• CC: Depression. 

• ROS: Positive for appetite loss and weight loss of 5 pounds (gastrointestinal/constitutional).

2. Extended, which inquires about the system directly related to the problem(s) identified in the HPI and a limited number (two to nine) of additional systems. In the following example, two systems—constitutional and neurological— are reviewed:

• CC: Depression. 

• ROS: Patient reports a 5-lb weight loss over 3 weeks and problems sleeping, with early morning wakefulness.

3. Complete, which inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional (minimum of 10) body systems. In the following example, 10 signs and symptoms are reviewed:

• CC: Patient complains of depression. 

• ROS:

a. Constitutional: Weight loss of 5 lb over 3 weeks 

b. Eyes: No complaints 

c. Ear, nose, mouth, throat: No complaints

d. Cardiovascular: No complaints

e. Respiratory: No complaints 

f. Gastrointestinal: Appetite loss 

g. Urinary: No complaints 

h. Skin: No complaints 

i. Neurological: Trouble falling asleep, early morning awakening 

j. Psychiatric: Depression and loss of sexual interest

PAST, FAMILY, AND/OR SOCIAL HISTORY (PFSH)

There are three basic history areas required for a complete PFSH: 

1. Past medical/psychiatric history: Illnesses, operations, injuries, treatments

2. Family history: Family medical history, events, hereditary illnesses 

3. Social history: Age-appropriate review of past and current activities 

The data elements of a textbook psychiatric history, listed below, are substantially more complete than the elements required to meet the threshold for a comprehensive or complete PFSH:

• Family history 

• Birth and upbringing 

• Milestones 

• Past medical history

• Past psychiatric history

• Educational history 

• Vocational history 

• Religious background 

• Dating and marital history

• Military history 

• Legal history 

The two levels of PFSH are:

1. Pertinent, which is a review of the history areas directly related to the problem(s) identified in the HPI. The pertinent PFSH must document one item from any of the three history areas. In the following example, the patient’s past psychiatric history is reviewed as it relates to the current HPI: 

• Patient has a history of a depressive episode 10 years ago successfully treated with Prozac. Episode lasted 3 months.

2. Complete. At least one specific item from two of the three basic history areas must be documented for a complete PFSH for the following categories of E/M services:

• Office or other outpatient services, established patient 

• Emergency department 

• Domiciliary care, established patient 

• Home care, established patient 

At least one specific item from each of the three basic history areas must be documented for the following categories of E/M services:

• Office or other outpatient services, new patient 

• Hospital observation services 

• Hospital inpatient services, initial care 

• Consultations 

• Comprehensive nursing facility assessments

• Domiciliary care, new patient 

• Home care, new patient

CHIEF COMPLAINT (CC)

The CC is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter.

DG: The medical record should clearly reflect the chief complaint.

HISTORY OF PRESENT ILLNESS (HPI)

The HPI 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. It includes the following elements:

• location; 
• quality; 
• severity;
• duration; 
• timing; 
• context; 
• modifying factors; and 
• associated signs and 
• symptoms.

Brief and extended HPIs are distinguished by the amount of detail needed to accurately characterize the clinical problem(s).

A brief HPI consists of one to three elements of the HPI. 

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.

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 which the patient may be experiencing or has experienced.

For purposes of ROS, the following systems are recognized: 

• Constitutional symptoms (e.g., fever, weight loss) 
• Eyes 
• Ears, Nose, Mouth, Throat 
• Cardiovascular 
• Respiratory 
• Gastrointestinal 
• Genitourinary 
• Musculoskeletal 
• Integumentary (skin and/or breast) 
• Neurological 
• Psychiatric 
• Endocrine 
• Hematologic/Lymphatic 
• Allergic/Immunologic  

A problem pertinent ROS inquires about the system directly related to the problem(s) identified in the HPI. 

DG: The patient's positive responses and pertinent negatives for the system related to the problem should be documented. 

An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems. 

DG: The patient's positive responses and pertinent negatives for two to nine systems should be documented.

A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.

 DG: At least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented.