The history is one of the three key
components of E/M documentation.The history is designed to
act as a narrative which provides information about the clinical
problems or symptoms being addressed during the encounter.The history is composed of
four building blocks:
All levels of history require a chief complaintand some form of HPI(or Interval History), but not all levels of
history require an ROSor PFSH.The following table shows
the individual requirements for each level of history.
E/M University Coding Tip: With the notable exception of
the rules for completing an extended HPI, the 1995 and 1997 E/M
guidelines are identical when it comes to the rules defining the
various levels of history.