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.
The Expanded Problem Focused History is the second lowest level of history. This history requires a chief complaint, a brief HPI(containing one to three HPIelements), plus one ROS. No PFSHis required.
Example
Level 3 office visit (99213) for a patient with allergic rhinitis
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CC : Follow-up for allergic rhinitis .
Interval History: The patient’s nasal congestion has significantly improved with steroid nasal spray and is now described as “mild” in severity.
ROS is negative for cough, hoarseness, or shortness of breath.
E/M University Coding Tip : Most physicians routinely over-document the history for the level 3 office visit. This example illustrates that an Expanded Problem Focused History does not require a lot of information. In this case, 2 HPI elements were used - location and severity. The ROS required review of only one system. In this case the respiratory system was reviewed.
