E/M Coding Tool: Patient History, Examination, and Medical Decision-Making

E/M Coding Tool Checklist
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E/M Coding Tool Checklist
The most important elements that should be included in an E/M (Evaluation and Management) coding tool are “patient history,” “examination,” and “medical decision-making.”
Patient History
Patient history is categorized into four types, detailed, comprehensive, expanded problem-focused, and problem-focused. Each type of patient history is made up of the elements of chief complaint (CC), history of present illness (HPI), review of systems (ROS), and past, family, and social history (PFSH). The history of present illness, review of systems, and past, family, and social history documented are dependent specifically upon the nature of the presenting problems and clinical judgment (American Medical Association, 2015). The chart below represents the progression of different elements needed for each type of patient history. It is compulsory for all the three elements presented in the table to be met to qualify for a specific type of history (chief complaint is indicated at all the levels).
Chief complaint (CC) is a brief statement that describes the problem, condition, symptom, diagnosis, or physical recommended return, among other vital factors that are reasons for the encounter. History of present illness (HPI) refers to the chronological description pertaining to the development of illness presently encountered by the patient, including the first signs and symptoms or the encounter experienced in a previous situation to the present. An extended or a brief HPI is mainly distinguished by the respective amounts of details required for the accurate characterization of the clinical problems. An extended HPI is principally made up of four or more HPI elements, while a brief HPI consists of one to three HPI elements (American Medical Association, 2015). 
Review of systems (ROS) entails body systems inventories often obtained through a series of questions that seek to facilitate the identification of signs and symptoms being experienced by the patient. It is categorized into problem complete, extended, and pertinent ROS. A problem pertinent ROS focuses on inquiring about the systems that have a direct relation to the problems explicitly identified in the HPI. An extended ROS seeks to inquire about the systems that are of direct relation to the problems identified in both the HPI ...