E&M Key Elements Defined

The key elements for E&M services are the history, exam, and medical decision making when using the 1995 or 1997 E&M guidelines. The examination criteria differ between the 1995 and 1997 E&M guidelines. This section describes the elements for each component in detail.

History - The HISTORY is composed of 4 elements:

1. Chief Complaint (CC) is usually a statement, in the patient's words, that gives the reason for the encounter.

2. History of Present Illness (HPI) is a chronological description of the patient’s present illness from onset of sign and/or symptom or from the previous encounter to present. The HPI is composed of eight (8) elements:

• Location (site of the problem/symptom)
• Quality (description or characteristics of the problem/symptom)
• Severity (intensity, degree or measure of the problem/symptom)
• Duration (length of time the problem/symptom has existed)
• Timing (regularity of occurrence, when the problem/symptom occurs)
• Context (events surrounding the occurrence of the problem/symptom)
• Modifying factors (factors attempted that may relieve/exacerbate/not impact the problem/symptom)
• Associated signs and symptoms (other problem/symptoms that accompany the main problem/symptom)

3. Review of Systems (ROS) is an inventory of body systems obtained through questions asked of patient regarding signs/symptoms which the patient may be experiencing or has experienced. The 'SYSTEMS' in the ROS include:

• Constitutional symptoms (e.g. fever, weight loss)
• Eyes
• Ears, nose, mouth and throat
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Integumentary (skin and/or breast)
• Neurologic
• Psychiatric
• Endocrine
• Hematologic/Lymphatic
• Allergic/Immunologic

There are 3 types of ROS.

1. Problem pertinent - only the system related to the present illness is reviewed.
2. Extended - 2 - 9 systems related to the illness are reviewed.
3. Complete - 10 or more systems related to the illness are reviewed.

Complete ROS: For a complete ROS, at least 10 organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least 10 systems must be individually documented.

If the ROS is completed by staff or on a form completed by the patient, it is likely that at least 10 systems would be individually addressed. However, if only nine systems are documented and there is no other indication that the other systems are negative, it would not qualify as a complete ROS.

4. Past, Family, and/or Social History (PFSH)

The PFSH consists of a review of three areas:

1. Past History
2. Family History
3. Social History

There are 2 types of PFSH:

1. Pertinent - A review of the history directly related to the problem with at least one item from any of the 3 history areas documented.
2. Complete:
   • A. A review of all history areas must be documented for:
     • - New Patients seen in the office, outpatient, domiciliary and home care settings
     • - Hospital Observation Services
     • - Initial Care in the Hospital
     • - Consultations
     • - Nursing Home comprehensive assessments

   • B. A review of two of the three history areas must be documented for:
   • - Established patients seen in the office, outpatient, domiciliary and home care settings
   • - Emergency Department services
   • - Nursing Home; subsequent visit

There are four types of history: problem focused, expanded problem focused, detailed and comprehensive. The type of history is determined based on the information gathered for each of the four elements and the following table: 

The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation by the physician supplementing or confirming the information recorded by others.

Exam - 1997 Guidelines​

There are 2 categories of exam

1. General Multi-System Exam
2. Single Organ System Exam
   • Cardiovascular
   • Ears, Nose, Mouth, and Throat
   • Eyes
   • Genitourinary (Female)
   • Genitourinary (Male)
   • Hematologic/Lymphatic/Immunologic
   • Musculoskeletal
   • Neurologic
   • Psychiatric
   • Respiratory
   • Skin

The examining physician regardless of specialty may select either exam category. CMS has identified specific elements for each type of exam. 

There are four types of exam:

1. Problem Focused
2. Expanded Problem Focused
3. Detailed
4. Comprehensive

Exam - 1995 Guidelines

As with the 1997 E&M guidelines, the 1995 guidelines also recognize four levels of exam. The following data identifies the body areas and/or organ systems and the number to be examined to qualify for each level.

*Based on the ambiguity of the CMS criteria for the exam component (i.e., CMS states 2-7 for both expanded problem-focused and detailed exams), your local Carrier guidelines may vary (e.g., CT state 2-4, for expanded problem-focused exam, and 5-7, for a detailed exam). Please check with your local Carrier to verify these specific guidelines are presently applicable in your state.

Medical Decision Making

There are four types of medical decision making.

1. Straightforward
2. Low
3. Moderate
4. High

The following table shows the progression of the elements required for each type of medical decision making. To qualify for a given type of decision making, two of the three elements in the table must be either met or exceeded. 

Table of Risk

The Table of Risk may be used to help determine whether the risk of significant complications, morbidity, and/or mortality is minimal, low, moderate, or high.