The levels of Evaluation and Management (E/M) services are based on four types of history: Problem Focused, Expanded Problem Focused, Detailed and Comprehensive.  Each type of history includes some or all of the following elements:

Key Components

  • Chief complaint (CC)
  • History of present illness (HPI)
  • Review of systems (ROS)
  • Past, family and/or social history (PFSH)

Contributory Factors

  • Counseling
  • Coordination of care
  • Nature of presenting problem
  • Time

Coordination of care with other providers can be used in case management codes. Time can be used for some codes for face-to-face time, non-face-to-face time, and unit/floor time. Time is used when counseling and/or coordination of care is more than 50 percent of your encounter. See guidelines or CPT book for more detail when using these contributory factors. 

The extent of history of present illness, review of systems, and past, family and/or social history
that is obtained and documented is dependent upon clinical judgment and the nature of the
presenting problem(s).

The chart below shows the progression of the elements required for each type of history. To
qualify for a given type of history, all three elements in the history table must be met. A chief
complaint is indicated at all levels.

History of Present Illness (HPI)

Review of Symptoms (ROS)

Risk of Complications and/or Morbidity and Mortality

Type of Decision Making






Problem Pertinent


Low Complexity

Extended Problem



Moderate Complexity

Extended Problem



High Complexities

Chief Complaint (CC): A concise statement describing the reason for the encounter. The CC should be clearly reflected in the medical record for each encounter and is usually stated in the patient’s words. The CC can be included in the description of the history of the present illness or as a separate statement in the medical record.

History of Present Illness (HPI): A description of the development of the patient’s present illness. The HPI is usually a chronological description of the progression of the patient’s present illness from the first sign and symptom to the present. It should include some or all of the following elements:

  • Location: What is the location of the pain?
  • Quality: Include a description of the quality of the symptom (i.e.  sharp pain)
  • Severity: Degree of pain for example can be described on a scale of 1 - 10
  • Duration: How long have you had the pain
  • Timing:  Describe when you have pain for example pain with exertion or pain in evening
  • Context: What is the patient doing when the pain begins
  • Modifying Factors: What makes the pain better or worse for example aspirin helps
  • Associated Signs and Symptoms: Physician based on assessment may ask about other sensations or feelings for example – do you experience pain while exercising
  • Two Levels of HPI:
    • Brief HPI: Requires one to three HPI elements (see above list)
    • Extended HPI: Requires four HPI elements or the status of three chronic problems (see 1997 guidelines for status of chronic conditions)