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Documentation Guidelines for CPT Evaluation and Management Services                         

Determine the Level of HISTORY


Level Type of History CC HPI ROS PFSH
1&2 Problem Focused Yes 1-3 elements N/A N/A
3 Expanded Problem Focused Yes 1-3 elements 1 N/A
4 Detailed Yes 4 elements 2-9 1 element
5 Comprehensive Yes 4 or more 10+ 2 est. pt.
3 new pt.

CC=chief complaint; HPI=hx of present illness; ROS=review of systems; PFSH=past family social hx

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