Appendix A 360 ||||||||||| APPENDIXES CPT copyright 2015 American Medical Association. All rights reserved. III. Documentation of E/M Services This publication provides definitions and documentation guidelines for the three key components of E/M services and for visits that consist predominantly of counseling or coordination of care. The three key components—history, examination, and medical decision making—appear in the descriptors for office and other outpatient services, hospital observation services, hospital inpatient services, consultations, emergency department services, nursing facility services, domiciliary care services, and home services. While some of the text of CPT has been repeated in this publication, the reader should refer to CPT for the complete descriptors for E/M services and instructions for selecting a level of service. Documentation guidelines are identified by the symbol •DG. The descriptors for the levels of E/M services recognize seven components that are used in defining the levels of E/M services. These components are E EE History EE Examination EE Medical decision making EE Counseling EE Coordination of care EE Nature of presenting problem E Time The first three of these components (ie, history, examination, and medical decision making) are the key components in selecting the level of E/M services. An exception to this rule is the case of visits that consist predominantly of counseling or coordination of care for these services time is the key or control- ling factor to qualify for a particular level of E/M service. For certain groups of patients, the recorded information may vary slightly from that described here. Specifically, the medical records of infants, children, adolescents, and pregnant women may have additional or modified information recorded in each history and examination area. As an example, newborn records may include under history of the present illness (HPI) the details of mother’s pregnancy and the infant’s status at birth social history will focus on family structure family history will focus on congenital anomalies and hereditary disorders in the family. In addition, information on growth and development and/or nutrition will be recorded. Although not specifically defined in these documentation guidelines, these patient group variations on history and examination are appropriate. A. 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: E EE Chief complaint (CC) EE History of present illness (HPI) EE Review of systems (ROS) E 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
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