Practice Management Book

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E/M History CriteriaAka: E/M Problem Focused History, E/M Expanded Problem Focused History, E/M Detailed History, E/M Comprehensive History

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  1. See also
    1. Encounter History
  2. General: Part of history may be obtained by form or staff
    1. Review of Systems
    2. Past Medical History
    3. Family History
    4. Social History
  3. History Type: 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
  4. History Type: 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
  5. History Type: 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
  6. History Type: 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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