E/M History Criteria

Aka: E/M History Criteria, E/M Problem Focused History, E/M Expanded Problem Focused History, E/M Detailed History, E/M Comprehensive History

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II. Approach

  1. See PQRST Mnemonic
  2. History of Present Illness (HPI): 8 Components (Must be asked by provider)
    1. Location
    2. Severity
    3. Timing
    4. Modifying factors
    5. Quality
    6. Duration
    7. Context
    8. Associated signs and symptoms
  3. Past Medical, Family History and Social History (PFSH) - may be obtained by form, scribe, CMA or other staff
    1. Past Medical History
    2. Family History
    3. Social History
  4. Review of Systems (ROS): 14 components (may be obtained by form, scribe, CMA or other staff_
    1. See Review of Systems
    2. Constitutional
    3. Eyes
    4. Ears, nose, mouth, throat
    5. Cardiovascular
    6. Respiratory
    7. Gastrointestinal
    8. Genitourinary
    9. Musculoskeletal
    10. Skin (integument, includes Breast)
    11. Neurologic
    12. Psychiatric
    13. Endocrine
    14. Hematologic or Lymphatic
    15. Allergic or immunologic

III. Type: History Problem Focused

  1. Criteria
    1. Establish chief complaint
    2. Brief history of present illness (HPI)
      1. Includes 1-3 components (see Encounter History)
  2. Related Codes
    1. E/M New Outpatient Visit
      1. CPT 99201
    2. E/M Established Outpatient Visit
      1. CPT 99212
    3. E/M Emergency Services
      1. CPT 99281
    4. E/M Consultation Services
      1. CPT 99241

IV. Type: History Expanded Problem Focused

  1. Criteria
    1. Establish chief complaint
    2. Brief history of present illness (HPI)
      1. Include 1-3 characteristics (see Encounter History)
    3. Problem pertinent Review of Systems (ROS)
      1. Includes 1 system (see Encounter History)
  2. Related Codes
    1. E/M New Outpatient Visit
      1. CPT 99202
    2. E/M Established Outpatient Visit
      1. CPT 99213
    3. E/M Emergency Services
      1. CPT 99282
      2. CPT 99283
    4. E/M Consultation Services
      1. CPT 99242

V. Type: History Detailed

  1. Criteria
    1. Establish chief complaint
    2. Extended history of present illness (HPI)
      1. Includes 4 characteristics (see Encounter History)
    3. Extended problem pertinent Review of Systems (ROS)
      1. Includes 2-9 systems (see Encounter History)
    4. Directly related history (one of the following)
      1. Family History (FHx) or
      2. Social history
  2. Related Codes
    1. E/M New Outpatient Visit
      1. CPT 99203
    2. E/M Established Outpatient Visit
      1. CPT 99214
    3. E/M Emergency Services
      1. CPT 99284
    4. E/M Consultation Services
      1. CPT 99243

VI. Type: History Comprehensive

  1. Criteria
    1. Establish chief complaint
    2. Extended history of present illness (HPI)
      1. Includes 4 characteristics (see Encounter History)
    3. Complete Review of Systems (ROS)
      1. Includes 10 or more systems (see Encounter History)
    4. Complete history (one of the following)
      1. Complete Family History (FHx) or
      2. Social history
  2. Related Codes
    1. E/M New Outpatient Visit
      1. CPT 99204
      2. CPT 99205
    2. E/M Established Outpatient Visit
      1. CPT 99215
    3. E/M Emergency Services
      1. CPT 99285
    4. E/M Consultation Services
      1. CPT 99244
      2. CPT 99245

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