E&M KEY COMPONENTS
VALLIAMMAL COLLEGE FOR
WOMEN
RAMJAN BEEVI.A
NAAN MUDHALVAN
DEPARTMENT OF BIOTECHNOLOG
unm1363222207205
KEY COMPONENTS
KEY COMPONENTS HISTORY
HISTORY The history element is made up of
EXAMINATIONS four types of history:
Chief Complaint (CC)
MEDICAL DECISION MAKING
History of Present Illness (HPI)
Review of Systems (ROS)
Past, Family & Social History
(PFSH)
CHIEF COMPLAINT (CC)
The chief complaint is a concise statement describing the symptom, problem, condition,
diagnosis, physician-recommended return, or other reason for a medical encounter.
A chief complaint must be present in all charts to count toward an E/M level of service.
The chief complaint (CC), a concise statement of the reason for a patient's encounter, is a
crucial key component of medical coding, as it forms the basis for understanding the patient's
primary concern and drives subsequent medical decision-making and coding.
IMPORTANCE OF KEY COMPONENTS
Basis for History: The chief complaint serves as the initial point of focus for gathering the
patient's history of present illness (HPI), review of systems (ROS), and past, family, and social
history (PFSH).
Coding Accuracy: The chief complaint is a key element in determining the appropriate
Evaluation and Management (E/M) code for a patient encounter
Patient Communication: The chief complaint is typically stated in the patient's own words,
HISTORY OF PRESENT ILLNESS (HPI)
DEFINITION HPI DESCRIPTORS
Defined as a "chronological description of patient's present condition from time of
onset to present". [Link]
May not always include a timeline of events. 2. Severity
May not be stated in the patient's own words if unable to speak (i.e. CVA, trauma,
etc.)Clues can be given by family or other 3. Duration
4. Associated Signs/Symptoms
Why is an HPI important
5. Quality
It helps doctors understand the reason for the patient's visit
It helps doctors determine the nature of the symptoms 6. Context
It helps doctors determine when the symptoms started 7. Timing
It helps doctors determine how the symptoms have
progressed. 8. Modifying Factors
HPI DESCRIPTORS
DURATION
LOCATION
Where on the body the symptom is occurring
Describes how long the symptom/pain has been present
i.e. chest pain or how long it lasts when the patient has it
i.e sore throat i.e. 20 minutes
i.e. knee swelling i.e. 3 years ago
SEVERITY ASSOCIATED SIGNS AND SYMPTOMS
A rank of the symptom/pain on a scale from 1- Describes the symptom/pain and other things that
10. happen when this symptom/pain occurs.
May also be described as severe, slightly, i.e. chest pain leads to shortness of breath
"worst I've ever had", mild, moderate,
Headache leads to visual disturbance
increasing, decreasing, progressive, well.
HPI DESCRIPTORS
QUALITY TIMING
How often the symptom or problem
o The patient's description of the occurs, and when it is most noticeable.
symptom or condition, including its Example: "The pain comes and goes
characteristics. throughout the day".
Example: "The pain is sharp and
stabbing".
The patient's description of the symptom
or condition,
o CONTEXT including its characteristics. MODIFYING FACTORS
•The circumstances or environment in What makes the symptom or problem
which the symptom or problem occurs. better or worse.
•Example: "The pain is worse when I Example: "Resting helps the pain, but
walk". walking makes it worse".
REVIEW OF SYSTEM
An inventory of body systems obtained through a series of questions, seeking to identify signs an patient may be
experiencing or may have experienced.
O Review of Systems (ROS) is a systematic method used by healthcare providers to gath history by asking questions abou
various body systems
O Constitutional (fever, weight loss, etc.) Eyes, Ear, Nose, Throat, Cardiovascular, Respiratory, ,Musculoskeletal,
Integumentary (skin and/or breast), Neurological, Psychiatric, Endocrine.
EXAMPLE OF HISTORY (ROS)
Neurological: Reports occasional lightheadedness but no history of seizures or [Link] depression, or mood
changes.
Endocrine: Denies excessive thirst, heat intolerance, or cold intolerance.
Hematologic/Lymphatic: Denies easy bruising or bleeding..
PFSH
The Past, Family and/or Social History(PFSH) includes a review in three areas: Past
History: The patient's past illnesses, operations, injuries, medications, allergies
and/or treatments.
In medical coding, "PFSH" stands for Past, Family, and Social History, a crucial
component of the history section used in Evaluation and Management (E/M) coding,
encompassing a review of a patient's past illnesses, family medical events, and social
activities.
Past history (patient's past experiences with illnesses, operations, injuries and treatments)
Family history (a review of medical events in the patient's family, including diseases which may be hereditary or place
a patient at risk.
Social history (age appropriate review of past and current activities)
EXAMINATION AND MDM
MEDICAL DECISION MAKING
EXAMINATION
In medical coding, "Medical Decision Making" (MDM) refers
to the complexity of a physician's cognitive work in
establishing a diagnosis and/or selecting a management
The extent and complexity of the physical option
examination performed by the provider during a MDM Complexity Levels:
patient encounter..
Straightforward:
The "examination" component assesses the scope This is the lowest level of MDM, typically involving a
and depth of the physical examination, including: limited number of problems and a straightforward
approach to diagnosis and treatment.
Organ Systems: Which organ systems were
Low Complexity:
examined.
This level involves a moderate number of problems and a
Complexity: The complexity of the examination
moderate amount of data review, with a moderate risk of
and the number of body areas examined. complications.
Documentation: How thoroughly the examination Moderate Complexity:
findings are documented. This level involves a greater number of problems, a more
in-depth data review, and a higher risk of complications.
High Complexity:
This is the highest level of MDM, involving a complex
interplay of multiple problems, extensive data review, and