Documentation guidelines revisited: the basic elements

There are potentially 25 elements to consider when making a decision about the level of history taken during the encounter. Many experts have offered ways of organizing and categorizing the different elements of the history as a component of the E/M services. Some are quite simple; others are complex. The CPT-DG explanation gives titles to the different levels of history: Problem Focused, Expanded Problem Focused, Detailed, and Comprehensive. These titles are helpful in understanding what type of history has been obtained, but a little hard to remember when grading the history and deciding on the proper E/M code. The grids on page 672 simplify the process of deciding what level of history was recorded and what level of E/M service is proper to submit. The number in each column indicates the minimum number of elements of the history components necessary to reach the E/M code in each row. These charts are not complete for grading the entire patient encounter, as the examination data and the medical decision-making are not yet included. Although the CC, HPI, ROS, and PFSH have been discussed separately. They are, in fact, a group that together determines the level of history in the medical record. The different levels of history-Problem Focused, Expanded Problem Focused, Detailed, and Comprehensive-are derived when each component of the history is evaluated as a group. How to select the proper code will be a separate discussion after all the components of the examination are reviewed. After all, that is the purpose of the DGs-to help the provider select the proper level of service. Upcoming articles in this series will discuss the examination, medical decision-making, and how to assimilate all the information and choose the proper E/M code.