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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 history is one of the three key components of E/M documentation.  The history is designed to act as a narrative which provides information about the clinical problems or symptoms being addressed during the encounter.  The history is composed of four building blocks:


  1. Chief Complaint
  2. History of Present Illness
  3. Review of Systems
  4. Past Medical, Family and Social History
Levels of History


The E/M guidelines recognize four “levels of history” of incrementally increasing complexity and detail:  


  1. Problem Focused
  2. Expanded Problem Focused
  3. Detailed
  4. Comprehensive
All levels of history require a chief complaint and some form of HPI (or Interval History), but not all levels of history require an ROS or PFSH.  The following table shows the individual requirements for each level of history.


Level of History HPI ROS PFSH
Problem Focused


None None

Expanded Problem  Focused


1 system None
Detailed Extended 2 – 9 systems 1pertinent PFSH
Comprehensive Extended 10 or more systems Complete PFSH


E/M University Coding Tip: With the notable exception of the rules for completing an extended HPI, the 1995 and 1997 E/M guidelines are identical when it comes to the rules defining the various levels of history.
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