The levels of Evaluation and Management (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:
Key Components
Contributory Factors
Coordination of care with other providers can be used in case management codes. Time can be used for some codes for face-to-face time, non-face-to-face time, and unit/floor time. Time is used when counseling and/or coordination of care is more than 50 percent of your encounter. See guidelines or CPT book for more detail when using these contributory factors.
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 history table must be met. A chief
complaint is indicated at all levels.
History of Present Illness (HPI)
Review of Symptoms (ROS)
Risk of Complications and/or Morbidity and Mortality
Type of Decision Making