American College of Physicians: Internal Medicine — Doctors for Adults ®


How to use the new E/M documentation guidelines

Part I: A step-by-step description of how to comply with HCFA's history-taking requirements

From the November 1997 ACP Observer, copyright 1997 by the American College of Physicians.

By Sharon Mikolanis

New documentation guidelines for evaluation and management (E/M) services that go into effect Jan. 1, 1998, promise to change the way physicians report and bill medical services.

The new guidelines, developed jointly by HCFA and the AMA, define the standards that Medicare carriers will use when reviewing physician documentation for E/M services. They define what documentation is needed to bill for medical history-taking, physical examinations and medical decision-making.

Once the new guidelines take effect, HCFA will randomly review charts before paying physicians; approximately1% of all medical records will undergo these prepayment audits. These won't replace retrospective auditing. Health professionals who don't comply with the guidelines or the claims review process will be denied payment for the billed service.

The new guidelines come at a time of increasing national attention on how health services are reported, billed and paid by Medicare. Recent audits of medical records in teaching hospitals and related facilities have raised concerns about inappropriate documentation and billing for physician services. A recent audit by the Office of the Inspector General concluded that HCFA inappropriately paid $23 billion during the fiscal year that ended Sept. 30,1996; this amounted to 14% of Medicare Part B fee-for-service payments that year.

Readers are urged to refer to CPT for the complete descriptors for E/M services and instructions for selecting a level of service.

Documenting patient histories

The level of E/M service you choose is based on the four types of history: problem-focused; expanded problem-focused; detailed; and comprehensive. The type of patient history depends on the nature of the presenting problems and includes some or all of the following elements: the chief complaint; the history of the present illness; the review of systems; and the past, family and/or social history.

The history of the present illness (HPI). The HPI is a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present.

The HPI may include one or more of the following elements: location, quality, severity, duration, timing, context, modifying factors, and associated signs and symptoms.

There are brief and extended HPIs, and they are distinguished by the amount of detail needed to accurately characterize the clinical problem(s). For a brief HPI, you'll need to show one to three elements in your documentation. For an extended HPI, you'll need to show at least four elements in your documentation.

The review of systems (ROS). The ROS is a series of questions that helps identify signs and/or symptoms that the patient may be experiencing or has experienced.

The following systems will be recognized as part of the ROS: constitutional symptoms (e.g., fever, weight loss, vital signs); eyes, ears, nose, mouth and throat; cardiovascular; respiratory; gastrointestinal; genitourinary; musculoskeletal; integumentary (skin and/or breast); neurological; psychiatric; endocrine; hematologic/lymphatic; and allergic/immunologic.

In addition, there are three types of ROS.

  • For the problem-pertinent ROS, your documentation must show the patient's positive responses and pertinent negatives for the system related to the problem identified in the HPI.
  • For the extended ROS, your documentation must show the patient's positive responses and pertinent negatives for two to nine systems related to the problem or problems identified in HPI.
  • For the complete ROS, your documentation must show that at least 10 organ systems have been reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissable. In the absence of such a notation, at least 10 systems must be individually documented.

The past, family and/or social history (PFSH). The PFSH consists of a review of the following:

  • A past history that discusses past experiences with illnesses, operations, injuries and treatments.
  • A family history that reviews medical events in patient's family, including diseases that may be hereditary or place a patient at risk.
  • A social history that includes an age-appropriate review of past and current activities.

For a pertinent PFSH, your documentation must include at least one specific item from any of these three history areas.

For a complete PFSH, your documentation must include the following:

  • At least one specific item from two of the three history areas must be documented for a complete PFSH for the following categories of E/M services: office/other outpatient services for established patients; emergency department; domiciliary and home care for established patients.
  • At least one specific item from each of the three history areas must be documented for a complete PFSH for the following categories of E/M services: office/other outpatient services for new patients; initial hospital inpatient services; consultations; comprehensive nursing facility assessments; domiciliary care and home care for new patients.

For E/M services including only an interval history (i.e., subsequent hospital care, follow-up inpatient consultations, and subsequent nursing facility care), there is no need to document the PFSH.


The types of HPI, ROS and PFSH you do will determine the level of E/M service you ultimately can report. For instance, if you are going bill for a comprehensive visit, you can't have a brief history.

The table above highlights the components of the history and level of specificity required to qualify for the various types of history. To qualify for a given type of history all three elements in the table must be met. A chief complaint is indicated at all levels.

Sharon Mikolanis is Senior Associate for Payment Policy in ACP's Washington, D.C., office.

Direct from HCFA: documenting a history

  • "The chief complaint, review of systems, and past, family, social history may be listed as separate elements of history or they may be included in the description of the history of the present illness."
  • "A review of system and/or past, family, social history obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by: describing any new review of system and/or past, family, social history information or noting there has been no change in the information; and noting the date and location of the earlier review of system and/or past, family, social history."
  • "The review of system and/or past, family, social history may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others."
  • "If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history."
  • "The medical record should clearly reflect the chief complaint which is defined as a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter, usually stated in the patient's words."


If counseling or coordination of care dominates more than 50% of a physician and patient/family encounter (face-to-face time in the office or other outpatient setting, floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M service.

For more information...

There are several ways to get a copy of the new E/M guidelines:

1. Got to ACP Online ( and follow the link to the documentation guidelines. This will automatically link you with the guidelines on the HCFA Web page.

2. Call Sharon Mikolanis at ACP's Washington Office (800-633-9400) or fax a request with your name and full address to 202-783-1347.

3. Go to HCFA's Web page on the internet at and click on &quotMedicare," then "Professional and Technical Information," and finally, "Documentation Guidelines." The guidelines are provided in WordPerfect 6.1 and Adobe formats.

4. Buy a copy of the July 1997 CPT Assistant from the AMA. Call 800-621-8335, or fax your request to 312-464-5600. The price per copy is $14.95 for AMA members, $19.95 for non-members.

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