Effective January 1, 2023, this information is no longer up-to-date. The material on this page covers only the 1995 and 1997 E/M guidelines and is no longer accurate. A new set of E/M guidelines was released in 2021, with some minor modifcations added for 2023. These new guidelines are now used to document all encounters in both the outpatient and inpatient settings. For the most recent E/M coding guidance, visit our home page here.
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The Comprehensive History is the highest level of history and requires a chief complaint, an extended HPI (four HPI elements OR the status of three chronic or inactive problems - if using the 1997 E/M guidelines), plus a 10 system ROS, plus a Complete PFSH .
Example
Level 3 H&P for a patient with chest pain
CC : Chest pain
HPI : The patient is a 65 year old male who developed sudden onset of chest pain, which began early this morning. The pain is described as “crushing” and is rated nine out of 10 in terms of intensity .
PMH is remarkable for GERD and hypertension
FH : Mother died at 78 of breast cancer; Father at 75 of CVA. No history of premature cardiovascular disease in first degree relatives.
SH : Negative for tobacco abuse; consumes moderate alcohol; married for 39 years
ROS
Constitutional--Negative for fevers, chills, fatigue
Cardiovascular--Negative for orthopnea, PND, positive for intermittent lower extremity edema
Gastrointestinal--Positive for nausea without vomiting; negative for diarrhea, abdominal pain
Pulmonary--Positive for intermittent dyspnea on exertion, negative for cough or hemoptysis
All other systems reviewed and are negative
This example illustrates the fact that the volume of documentation does not necessarily need to be excessive in order to qualify for a Comprehensive History. The information included is useful and clinically relevant, but not obsessively detailed. Note that ROS has been abbreviated by using the legal shortcut, “All other systems reviewed and are negative.” |
