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Eli's Rehab Report

Find Your Place in History

Published on Sat Sep 13, 2003 Print Friendly and PDF PDF

The following chart outlines the various levels of history that you must document to report the corresponding E/M code. Note that history is just one E/M element that determines your code level. You must also document the appropriate examination and medical decision-making elements to justify reporting these codes.

A problem-focused history ( CPT 99201 ) includes:
 

  • Chief complaint
     
  • Brief history of present illness (one to three elements)
     
  • No review of systems or past, family or social history is required
     
    An expanded problem-focused history (99202) includes:
     
  • Chief complaint
     
  • Brief history of present illness (one to three elements)
     
  • Problem-pertinent review of systems (one system)
     
  • No past, family, social history is required

    A detailed history (99203) includes:
     

  • Chief complaint
     
  • Extended history of present illness (four or more elements, or three or more chronic or inactive conditions if 1997 Medicare E/M guidelines are being followed)
     
  • Problem-pertinent system review extended to include a review of a limited number of additional systems (two to nine systems)
     
  • Pertinent past, family, and/or social history directly related to the patient's problems (one or two areas of history)
     
    A comprehensive history (99204, 99205) includes:
     
  • Chief complaint
     
  • Extended history of present illness
     
  • Review of systems that is directly related to the problem(s) identified in the history of the present illness plus a review of all additional body systems (more than 10 systems)
     
  • Complete past, family and social history (two or three history areas).

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