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History of Present Illness

Jen Godreau, BA, CPC, CPEDC

Content Director
Inhealthcare’s Supercoder

March 9, 2010
Four parts of a History
Chief Complaint (CC)

History of Present Illness (HPI)

Past Medical Family Social History


Review of Systems (ROS).

99202: A level 2
new patient office visit requires an expanded problem-focused history.
An expanded problem focused history requires:
Type CPT
Required for sick Required for sick
HPI Brief 1-3
ROS Problem
Pertinent 1 system
8 Areas That Help Determine
8 Areas That Help Determine
Represents the chief complaint
or signs or symptoms

The time of day the patient
experienced the signs
and symptoms
8 Areas That Help Determine
Just how serious is the
patient‘s condition?

How long have the
patient's signs and symptoms
been present?
8 Areas That Help Determine
Modifying Factors
What the patient did to
alleviate pain or exacerbate

Associated signs and symptoms

Are any other problems the
patient has in addition to
the chief complaint?
HPI Element Principles
1997 EM Guidelines allow you to count the
status of chronic conditions
• 1-2 chronic conditions counts as a brief HPI; 3 or
more is an extended HPI

Physician must obtain and document the HPI

• must indicate his actual review and interaction
Guidelines have never defined if staff
are allowed to document the history of
present illness
Ancillary staff does not have permission
to collect the HPI
Ancillary staff can collect ROS and PFSH

E/M service code values include physician

work for performing the HPI.
No double dipping. You get
credit for any given HPI element
only once
In a note that indicates:
“dull, aching back pain,”

1 quality
Let’s try it!
Est patient here today for sore throat (location) and productive
cough (associated signs and symptoms). Throat hurts worst at
night (timing) and is a 7 (severity)

The physician documented four elements in the note. Four
elements counts as an extended HPI. For an established
patient visit, an extended HPI supports a level greater than
or equal to 99214. For a new patient visit code, extended
HPI supports an E/M level greater than or equal to 99203
provided the visit meets all other required elements as
What Is ROS?
Physician reviews systems directly related
to the problem or problems identified in
the HPI portion of the E/M and a number of
additional systems.
CPT defines ROS as:
“an inventory of body systems obtained through a
series of questions seeking to identify signs
and/or symptoms that the patient may be
experiencing or has experienced.”
ROS “helps define the problem,
clarify the differential diagnosis,
identify needed testing, or serves
as baseline data on other systems
that might be affected by any
possible management options.”
A patient reports to the FP complaining of a headache.
The FP inquires about how long the headache has
lasted, and a few other questions to rule out migraines.
The FP discovers that the patient has not taken any
medication for the headaches, he prescribes several
over-the-counter options to deal with the condition, and
tells the patient to come back in for another exam if the
headaches worsen or increase in frequency.
 In this instance, you can only consider 1 system
reviewed (neurological), since the FP has apparently
only inquired about the system directly related to
the problem.
Count These Systems
CPT identifies the following ROS
What Are the Different ROS Levels?
Problem-pertinent: When the physician reviews one system, you
have a problem-pertinent ROS.
This ROS level can support up to a level-two new patient E/M
(99202, an expanded problem-focused history; an expanded
problem-focused examination; and straightforward medical
decision making) or a level-three established patient service
(99213, … an expanded problem-focused history; an expanded
problem-focused examination; medical decision-making of low
What Are the Different ROS Levels?
Extended: When the physician reviews two to nine
systems, the encounter is an extended ROS.
Extended ROS can support up to a level-three new
patient service
(99203, … a detailed history; a detailed
examination; and medical decision-making of low
complexity) or level-four established patient
service (99214, … a detailed history; a detailed
examination; medical decision-making of
moderate complexity).
What Are the Different ROS Levels?
Complete: For a complete ROS, most insurers accept a
review of 10 or more systems with all others documented.
Per CPT, a complete ROS requires a review of all additional
body systems. This would include 14 systems. The CMS
Documentation Guidelines define a complete ROS as
covering at least 10 organ systems.
 “A complete ROS inquires about the system(s) directly related to the
problem(s) identified in the HPI plus all additional body systems,”
the E/M Documentation Guidelines state.
 With a complete ROS, reporting a 99204, 99205 or is possible --
depending on other encounter specifics.
An internist sees a patient with multiple chronic conditions:
COPD, CHF, hypertension, and diabetes. The physician asks
questions about 10 of the systems, including constitutional,
eyes, cardiovascular, respiratory, integumentary, neurological,
and endocrine. He documents the positive and pertinent
negative responses for 10 of the systems and writes: 10 of 14
systems obtained, remainder of systems are negative.

This documentation would count as a complete ROS.

You can use a form or template to record
Keep any form as part of the medical
When referring to old forms, include the
review date and location of the
previously recorded information.
Include all 14 systems on form.
Don’t need until you get to a detailed history 99214 – or on the
new patient side a 99203.
In the ED, you’d be talking about a 99284 (… a detailed history; a
detailed examination; and medical decision making of moderate
complexity …)
A complete PMFSH addresses 2 or 3 of the PMFSH elements.
Established patient visit requires 2 of 3
Initial visits and consults requires 3 of 3

A complete PMFSH might support up to 99285.

99204 99205 99215
99219/99220 99222/99223
99254 99255
Patient History
Past medical: look for information on the
patient’s allergies, current medications, past
illnesses and surgeries, and any conditions
that may be relevant to the presenting
Example: A patient is taking insulin to treat her
diabetes. The physician notes this, in case he
decides to prescribe medication that may
interact negatively with insulin.
Patient History
Family history : a review of medical events in the
patient’s family, including diseases that may be
hereditary or place the patient at risk. Also includes any
inheritable condition or disease that is relevant to why
the patient is seeking medical attention.
Example: A patient presents with rectal bleeding. The
physician notes that the patient’s family has a history of
colon cancer, this will affect treatment
Patient History
 Social history is just as important as family and
past history.
Items you should include:
• workplace
• living conditions
• marital status
• age-appropriate review of past and
current activities
 A 50-year-old man presents to the ED with chest pain.
He has been experiencing shortness of breath and
upper extremity discomfort for the past four hours. The
patient has a history of coronary artery disease (CAD)
and hypertension (HTN). He is and has been a smoker
for 20 years, and his father had cardiovascular disease
and died of an acute myocardial infarction (MI) at age
 In this instance, the physician addressed past (CAD, HTN),
family (father’s CAD), and social (smoker) histories. 3
PFSH supports a complete PFSH.

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Codes 99201 99202 99203 99204 99205

History Problem Expanded Detailed Comprehensi Comprehensi

Focused Problem ve ve
Exam Problem Expanded Detailed Comprehensi Comprehensi
Focused Problem ve ve
Decision Straight Straight Low complex Moderate High complex
Making forward forward complex
Time FF 10 20 30 45 60

Key # 3 of 3 3 of 3 3 of 3 3 of 3 3 of 3
Office Visits – Established
Codes 99211 99212 99213 99214 99215

History Not Required Problem Expanded Detailed Comprehensi

Focused Problem ve
Exam Not Required Problem Expanded Detailed Comprehensi
Focused Problem ve
Decision Not Required Straight Low ComplexMod ComplexHigh complex
Making Forward
Time FF 5 10 15 25 40

Key # 2 of 3 2 of 3 2 of 3 2 of 3 2 of 3
Levels of History
Level of History Chief History of Present Illness Review of Systems (ROS) Past, Family, Social History
Complaint (HPI) (PFSH)
CPT Medicare CPT Medicare CPT Medicare

Problem Focused Required Brief 1-3 elements Not Required Not Required

Expanded Required Brief 1-3 elements Problem- 1 system Not Required

Problem Focused Pertinent

Detailed Required Extended 4 + elements ORExtended 2-9 systems Pertinent 1 element

3+ chronic or

Comprehensive Required Extended 4 + elements ORComplete 10 systems Complete 2 or 3 elements

3+ chronic or