History

There are 4 levels of history:

a) “problem-focused,” typical of a 99212

b) “expanded-problem-focused,” typical of 99202 or 99213 office visits,

c) “detailed,” typical of 99203 or 99214 office visits, or

d) “comprehensive,” typical of level 99204, 99205, or 99215 office visits.

 

An element of the HPI is defined as one of the following:

1. duration
2. timing
3. context/onset
4. location
5. quality
6. severity
7. modifying factors
8. associated signs/symptoms

 

A problem focused history consists of only a CC and 1-3 of the 8 elements in the HPI; it is typical of a 99212 only.

 

An expanded problem-focused history consists of a CC, 1-3 of the 8 elements in the HPI, and only pertinent ROS information (but at least one system).  This is typical of a 99202 or 99213.

 

A detailed history should include a CC, >3 elements in the HPI, 2 systems reviewed in the ROS, and at least one item from the PMH, FH, or SH.  This is typical of a 99203 or 99214.

 

A comprehensive history should include a CC, >3 elements in the HPI, 10 systems reviewed in the ROS, one item from the PMH, one item from the FH, and one item from the SH.  A comprehensive history is typical of a 99204, 99205, and 99215.

 

ROS is defined by CPT as pertaining to the following organ systems:

1. constitutional (fever, fatigue, etc.)
2. eyes
3. ENT
4. Cardiovascular
5. respiratory
6. GI
7. GU
8. musculoskeletal
9. skin
10. neuro
11. psych
12. endocrine
13. hematological/lymphatic
14. allergic/immunological