The Three Key Components: History, Exam and Medical Decision-Making

By Erica Schwalm


Evaluation & Management codes are divided based on several factors.  Location and patient status (e.g. inpatient, outpatient, office visit, ER visit, observation, new patient, established patient, etc.) and, in some cases, patient age (e.g. inpatient critical care services).  That’s the easy part!   Many of the categories/subcategories of E/M codes are further divided into “levels” of service based on the intensity of the service.  This is the tricky part.  How do you measure the intensity of a service?  The patient, the condition(s), underlying conditions and countless other things can affect how intense a service will be.  Auditors, consultants and physicians alike agree that reporting the appropriate level of service is not an exact science and that certain gray areas do still exist.  However, there are areas of the E/M guidelines that are quite clear, specifically when it comes to the three key components, which will be discussed in detail. 


Providers are responsible for assigning the appropriate level of service, therefore are expected to understand the E/M documentation guidelines.  Misunderstanding the guidelines leads to noncompliant habits such as “undercoding”, “overcoding”, reporting for reimbursement rather than medical necessity or consistently billing the same level of service.  Whether intentional or not, consistent noncompliant practices is a serious act – ignorance is not a defense against fraud. 


The first step is to understand the E&M documentation guidelines.  In most cases, the three key components – history, examination, and medical decision making – are the primary components in selecting a level of service.  Each of the three key components must be thoroughly understood: 


There are four types/extents of history:

•         PF - Problem focused (CC, brief HPI)

•         EPF - Expanded problem focused (CC, brief HPI, pertinent ROS)

•         D - Detailed (CC, extended HPI, extended ROS, pertinent PFSH)

•         C - Comprehensive (CC, extended HPI, complete ROS, complete PFSH)

To determine the correct type/extent of history, you must understand the four elements of history: CC, HPI, ROS, and PFSH, which are described in detail below.

* CC (Chief Complaint)

The CC, defined as "a concise statement describing the symptom, problem, condition, diagnosis or other factors, usually stated in the patient's words" is required at all history levels and must be clearly documented.

* HPI (History of Present Illness)

HPI is defined as a chronological description of the development of the patient's present illness from the first sign/symptom to the present.

There are two levels of HPI-brief and extended. A brief HPI consists of 1 - 3 of the following elements; an extended HPI consists of 4 - 8 of the following elements:

Ψ       Location - where problem, pain or symptom occurs, e.g. specific body area, diffuse or localized, unilateral or bilateral, etc.

Ψ       Duration - how long problem, pain or symptom has persisted, e.g. since last week, for 5 years, etc.

Ψ               Severity - description of severity of problem, pain or symptom, e.g. 1 - 10 rating, mild moderate, severe or may be assessed by                     

nonverbal signs of discomforts.

Ψ               Quality - description of problem, symptom or pain, e.g. dull, aching, stabbing, burning, constant, chronic, acute, intermittent, stable,

improving, worsening.

Ψ       Timing - when the problem, pain or symptom occurs, e.g. worse in the morning or at night, continuous, etc.

Ψ               Modifying factors - actions taken to make the problem, symptom or pain better of worse, e.g. pain relievers help with pain,          

bending makes pain worse, etc.

Ψ               Context - instances that can be associated with the problem, pain or symptom, e.g. while standing for a long time, when standing, etc.

Ψ       Association signs and/or symptoms - Other problems that occur with primary problem, symptom or pain, e.g. stress causes headaches



* ROS (Review of Systems)

The ROS is defined as "an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced."

There are three levels of ROS - problem pertinent, extended and complete. Problem pertinent requires documentation of one of the recognized systems, extended requires 2 - 9 of the systems and a complete ROS requires documentation of 10 or more systems.

The following systems are recognized:

•     Constitutional symptoms (e.g., fever, weight gain or loss, fatigue, weakness, etc)

•     Eyes (e.g., double vision, blurred vision, etc.)

•     Ears, Nose, Mouth, Throat (e.g., difficulty swallowing, sinuses, etc.)

•         Cardiovascular (e.g., chest pain)

•         Respiratory (e.g., SOB)

•     Gastrointestinal (e.g., stomach pain, heartburn, bowel movements)

•     Genitourinary (e.g., dysuria, burning, frequency, etc.)

•     Musculoskeletal (e.g., pain, stiffness, pain ,swelling, etc.)

•     Integumentary (e.g., rashes, pain, lumps)

•     Neurologic (e.g., seizures, fainting, headaches, numbness, etc.)

•     Psychiatric (e.g., sleeping habits, feelings, etc.)

•     Endocrine (e.g., thyroid problems, excessive thirst or sweating, etc.)

•     Allergic/immunologic (e.g., allergies, reactions, immune symptoms of problems)

* (PFSH) Past, Family and Social History

Past History - a review of prior illnesses, injuries, operations, hospitalizations, medications, etc.

Family History - a review of medical events in the patient's family that are hereditary or place the patient at risk.

Social History - review of habits such as smoking or drug use, living arrangements, occupation, etc.

There are two levels of PFSH - pertinent and complete. Pertinent requires that one specific item from any of the three history areas be documented. A complete PFSH is one specific item from all three areas for new patients and consults. Only two history areas are required for established patients.



** When documenting a complete ROS, document all positive and pertinent negative responses. A phrase such as "all other systems negative" is acceptable if the physician reviewed all systems.

**The ROS/PFSH may be recorded on a form by a staff member or by the patient. To document the physician reviewed the information, there must be notation supplementing or confirming the information recorded by others and the location of the form must be referred to in the chart.

** A ROS/PFSH recorded at an earlier encounter does not need to be rerecorded as long as there is evidence the physician reviewed and updated the previous information. This may be documented by describing any new ROS/PFSH information or noting any changes/no changes AND noting the date and location of the earlier ROS/PFSH.


Use this chart to determine the type of history based on the extent of HPI, ROS and PFSH. Note: CC (chief complaint) is required at all levels. To qualify for a given type of history all elements in the table must be met:

Type of History










PF - Problem focused




Brief (1-3)






EPF - Expanded problem focused




Brief (1 -3)


Problem Pertinent (1)




D - Detailed




Extended (4+)


Extended (2 - 9)


Pertinent (1 Hx area)


C - Comprehensive




Extended (4+)


Complete (10+)


Complete (3 new pt., 2 est. pt)






2. Exam (1995 Guidelines):

The next key component is the examination. Like history, there are four exam types - PF, EPF, D, C - To determine the extent of examination performed, see the descriptions below.

Type of Exam


Performed and Documented:




Limited exam of one body area or organ system

1 body area or organ system




Limited exam of affected body area/organ system + any other symptomatic or related body area/organ system.

2-7 body areas and/or organ systems

(Or 2 – 4 depending on auditor)





Extended exam of the affected body area(s)/organ system(s) + other symptomatic or related body areas/organ systems

2-7 body areas and/or organ systems with at least 1 in detail

(Or  5 – 7 depending on auditor)




General multisystem examination

8 or more findings about the organ systems and/or body areas


Organ systems and body areas according to the 1995 CMS guidelines:

•     Constitutional (Vitals and general appearance of patient e.g., development, nutrition, body habitus, deformities, attention to grooming)

•     Eyes (Inspection of conjunctivae and lids; exam of pupils and irises)

•     Ears, nose, mouth and throat

•     Cardiovascular (exam of peripheral vascular system by observations and palpation, e.g. swelling, varicosities, pulses, temperature, edema, tenderness)

•     Respiratory (assessment of respiratory efforts, percussion and palpation of chest, auscultation of lungs)                          

•    Gastrointestinal (examination of abdomen)

•     Musculoskeletal

•     Skin (inspection and/or palpation of skin and subcutaneous tissue)

•    Neurological (coordination, deep tendon reflexes and/or nerve stretch test with notation of pathological reflexes and examination
of sensation)                                                                                                                                  

•     Psychiatric (mood and affect; orientation to time place and person)

•     Lymphatic (palpation of lymph nodes)

Body areas:

•     Head/face

•     Neck

•      Chest                                                                                                                              

•      Abdomen

•     Genitalia, groin, buttocks

•     Back, including spine

•      Each extremity

** Don't count both the body area and the organ system. For example if you are counting the spine and two extremities for body areas, you cannot also get separate credit for the musculoskeletal system.

CMS Documentation guidelines:

1.    Specific abnormal and relevant negative findings of the exam of the affected or symptomatic areas/systems should be documented. A notation of "abnormal" without elaboration is insufficient.

2.    Abnormal or unexpected findings on the examination of any asymptomatic area/system should be described.

3.    A brief statement or notation indicating "negative" or "normal" is sufficient to document normal findings related to unaffected areas or systems.




3. Medical Decision Making (MDM)

The last key component is medical decision making, which is composed of the presenting problem, amount and/or complexity of data to be reviewed, and risk.

There are four types of MDM:

•     Straightforward

•     Low complexity

•     Moderate complexity

•     High complexity                                                      

The first element is the Number of diagnosis and management options, which is calculated using a point system. The more complex the problem, the more points are given. Use the following chart to determine how many points will be given.


1.       Number of Diagnosis & Management Options:

Category of Problem(s)


Occurrence of

P ruble m(s)










Self-limited or minor problem


(max 2)










Established problem, stable or improved












Established problem, worsening












New problem, no additional workup planned


(max 1)










New problem, additional workup planned
















Next is Amount and/or Complexity of Data Reviewed, which is also based on a point system. Use the following chart to determine points for this element.


2. Amount and/or Complexity of Data Reviewed:                                                                             

Data Type:




Lab(s) ordered and/or reviewed




X-ray(s) ordered anchor reviewed




Medicine section (90701 - 99199)ordered and/or reviewed (ex. PT, EMG, psych)




Discussion of test results with performing physician




Decision to obtain old records and/ or obtain history from some one other than the patient




Review and summary of old records and/or discussion with other health provider




Independent visualization of images, tracing or specimen.








Last step is determining the level of risk. There are four levels of risk:

•     Minimal

•     Low

•     Moderate

•     High

Use the chart on the next page to determine if the overall risk is minimal, low, moderate or high based on the presenting problem, tests ordered and management options selected.

**The highest one in any one category determines the overall risk. For example, if the presenting problem and tests ordered both fall into the low category but the management options fall into the moderate category, the overall risk for the encounter would be moderate. 


3.        TABLE OF RISK (The highest one in any one category determines the overall Risk)


Level of Risk

Presenting Problem(s)

Diagnostic Procedure(s) Ordered

Management Option(s) Selected






* One self-limited or minor problem, e.g., cold, insect bile, tinea corporis



* Lab tests requiring venipuncture

* Chest x-rays   


* Urinalysis

* Ultrasound

 * KOH prep



* Rest

* Gargles

* Elastic bandages

* Superficial dressings






*Two or more self-limited or minor problems

* One stable chronic illness, e.g. well controlled HTN, NIDDM, cataract, BPH

* Acute, uncomplicated illness or injury, e.g., allergic rhinitis or simple sprain, cystitis 



*Physiologic tests not under stress, e.g. PFTs

*Non-cardiovascular imaging studies w/ contrast, e.g. barium enema

* Superficial needle biopsies

* Lab tests requiring arterial puncture

* Skin biopsies



* Over-the-counter drugs

* Minor surgery w/ no identified risk factors


* IV fluids w/o additives






* One or more chronic illnesses with mild exacerbation, progression or side effects of treatment

* Two or more stable chronic illnesses

* Undiagnosed new problem with uncertain prognosis, e.g. lump in breast

* Acute illness with systemic symptoms, e.g. pyelonephritis, colitis.

* Acute complicated injury, e.g. head injury with brief loss of consciousness



* Physiologic tests under stress, e.g. cardiac stress test, fetal contraction stress tests

* Diagnostic endoscopies w/ no identified risk factors

* Deep needle or incisional biopsies

* Cardiovascular imaging studies with contrast and no identified risk factors e.g. arteriogram, cardiac cath

* Obtain fluid from body cavity, e.g. lumbar puncture, thoracentesis, culdocentesis

* Minor surgery with identified risk factors

* Elective major surgery (open, percutaneous, or endoscopic) with no identified risk factors

*Prescription drug management

*Therapeutic nuclear medicine IV fluids with additives

* Closed Tx of Fx or dislocation w/o manipulation





* One or more chronic illness with severe exacerbation, progression, or side effects of treatment

* Acute or chronic illnesses or injuries that pose a threat to life or bodily function, e.g. multiple trauma, acute MI, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others.

* An abrupt change in neurological status, e.g. seizure, TIA, weakness, sensory loss.


* Cardiovascular imaging studies with contrast with identified risk factors

* Cardiac electrophysiological tests

* Diagnostic endoscopies with identified risk factors

* Discography

* Elective major surgery with identified risk factors

* Emergency major surgery

* Parenteral controlled substances

* Drug therapy requiring intensive monitoring for toxicity

* Decision not to resuscitate or to de-escalate care because of poor prognosis.


Use the chart below to determine the overall medical decision making by bringing the information down from the other three charts. The overall MDM is determined by the highest 2 out of the 3 categories.

For example: You scored 3 points for diagnosis and management options, 2 points for data reviewed and the level of risk was moderate. In this scenario, the overall MDM is moderate.


Overall Complexity of Medical Decision Making


1. Number of Diagnosis/Management Options


2. Amount and Complexity of Data to be reviewed


3. Risk




0- 1






























(Overall MDM is determined by the highest 2 out of the 3 above categories)





ό       Identify chief complaint

ό       Count the number of HPI elements

ό       Count the number of ROS elements

ό       Count the number of PFSH elements

ό             Determine extent of history

ό       Count the number of body areas and organ systems examined

ό             Determine the extent of examination

ό       Count the points for number of diagnosis and management options

ό       Count the points for amount and complexity of data reviewed

ό       Determine level of risk

ό            Determine overall complexity of medical decision making

The next step is to determine the correct level of service.

** New patient visits and consultations require that all three of the key components are met.

** Established patient visits only require two of the three key components.



- New patient office visit with a comprehensive history, comprehensive examination and medical decision making of moderate complexity. 99204

- New patient visit with comprehensive history, detailed exam and medical decision making of moderate complexity. 99203

- Established patient office visit with a detailed history, detailed exam and low MDM. 99214

- Established patient office visit with a comprehensive history, expanded problem focused exam, and straightforward medical
decision making. 99213                                                                                    

See the charts on the next page for requirements of some levels of service and average times.


** Remember: Time is the least significant factor in determining the level of service

The exception to this is in the case where counseling and/or coordination of care dominates the encounter (face-to-face time in the office setting). If more that 50% of the encounter is spent on counseling/coordination of care, then time is considered the controlling factor.

If the physician elects to report the level of service based on counseling and/or coordination of care, the total length of time of the encounter should be documented and the record should describe the amount of time and nature of the counseling and/or activities to coordinate care.




PF – problem focused

EPF – expanded problem focused

D – detailed

C – comprehensive

MDM – medical decision making

SF – straightforward



Established Patient Office Visits (2/3)

Level of Service








Avg. time (minutes)






















































New Patient /Office Consultations (3/3)

Level of Service








Avg. time (minutes)












99202/ 99242










99203/ 99243










99204/ 99244










99205/ 99245