an extended review of systems (ROS), and pertinent past, family, and/or social history (PFSH). Elements Required for Each Type of History TYPE OF HISTORY CC HPI ROS PFSH Problem Focused Required Brief N/A N/A Expanded Problem Focused Required Brief Problem Pertinent N/A Detailed Required Extended Extended Pertinent Comprehensive Required Extended Complete Complete While documentation of the CC is required for all levels, the extent of information gathered for the remaining elements related to a patient’s history depends on clinical judgment and the nature of the presenting problem. Chief Complaint (CC) A CC is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter. The CC is usually stated in the patient’s own words. For example, patient complains of upset stomach, aching joints, and fatigue. The medical record should clearly reflect the CC. Table 1: Elements for Each Type of History Evaluation and Management Services Guide MLN Booklet Page 8 of 23 MLN006764 February 2021 History of Present Illness (HPI) 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. HPI elements are: ● Location (example: left leg) ● Quality (example: aching, burning, radiating pain) ● Severity (example: 10 on a scale of 1 to 10) ● Duration (example: started 3 days ago) ● Timing (example: constant or comes and goes) ● Context (example: lifted large object at work) ● Modifying factors (example: better when heat is applied) ● Associated signs and symptoms (example: numbness in toes) The two types of HPIs are brief and extended. 1. A brief HPI includes documentation of one to three HPI elements. In this example, three HPI elements – location, quality, and duration – are documented: ● CC: Patient complains of earache ● Brief HPI: Dull ache in left ear over the past 24 hours 2. An extended HPI: ● 1995 documentation guidelines – Should describe four or more elements of the present HPI or associated comorbidities ● 1997 documentation guidelines – Should describe at least four elements of the present HPI or the status of at least three chronic or inactive conditions For reporting services furnished on and after September 10, 2013, to Medicare, you may use the 1997 documentation guidelines for an extended HPI along with other elements from the 1995 documentation guidelines to document an E/M service. In this example, five HPI elements – location, quality, duration, context, and modifying factors – are documented: ● CC: Patient complains of earache. ● Extended HPI: Patient complains of dull ache in left ear over the past 24 hours. Patient states he went swimming 2 days ago. Symptoms somewhat relieved by warm compress and ibuprofen. Effective January 1, 2021, practitioners will have the choice to document office/outpatient E/M visits via medical decision making (MDM) or time. CMS is adopting the CPT’s revised guidance, including deletion of CPT code 99201. CMS has also finalized separate payment rates for the remaining nine E/M codes. For more information, review the CY 2021 Physician Fee Schedule Final Rule, page 301 and the CPT® Evaluation and Management webpage. Page 9 of 23 MLN006764 February 2021 Evaluation and Management Services Guide MLN Booklet Review of Systems (ROS) ROS is an inventory of body systems obtained by asking a series of questions to identify signs and/or symptoms the patient may be experiencing or has experienced. These systems are recognized for ROS purposes: ● Constitutional Symptoms (for example, fever, weight loss) ● Eyes ● Ears, nose, mouth, throat ● Cardiovascular ● Respiratory ● Gastrointestinal ● Genitourinary ● Musculoskeletal ● Integumentary (skin and/or breast) ● Neurological ● Psychiatric ● Endocrine ● Hematologic/lymphatic ● Allergic/immunologic The three types of ROS are problem pertinent, extended, and complete. 1. A problem pertinent ROS inquires about the system directly related to the problem identified in the HPI. In this example, one system – the ear – is reviewed: ● CC: Earache. ● ROS: Positive for left ear pain. Denies dizziness, tinnitus, fullness, or headache. 2. An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number (two to nine) of additional systems. In this example, two systems – cardiovascular and respiratory – are reviewed: ● CC: Follow-up visit in office after cardiac catheterization. Patient states “I feel great.” ● ROS: Patient states he feels great and denies chest pain, syncope, palpitations, and shortness of breath. Relates occasional unilateral, asymptomatic edema of left leg. Evaluation and Management Services Guide MLN Booklet Page 10 of 23 MLN006764 February 2021 3. A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional (minimum of ten) organ systems. You must individually document those systems with positive or pertinent negative responses. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, you must individually document at least ten systems. In this example, ten signs and symptoms are reviewed: ● CC: Patient