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A chief complaint has to be stated at every level for any kind of history to be qualified for.
b) History of Present Illness (HPI) -- it is a description made in a chronological order of the presenting problem or illness from the very first symptom or sign or from the initial encounter to the current one. HPI can be either brief or extended and the two are differentiated by the depth of detail involved in documentation. A brief one has one to three elements while an extended one can have four or more elements (1997 criteria only).
c) Past, Family and Social History (PFSH) -- past history covers the history of significant illnesses, injuries, hospitalizations, allergies, age appropriate immunization status and allergies. Family history has to do with a record of the state of health of parents, children, siblings and the causes of death of these members of the family. It also covers health complaints that are connected with the presenting illness. Social history has to do with marital status/living arrangements, employment status, professional history, drug use history, sexual history and other social factors that are relevant to the current situation (Evaluation and Management (E/M Services).
2. Physical Examination
The extent and nature of examination done and documented depends on the judgment of the clinician, the history of the patient as well as the nature and kind of the presenting problem. A physical examination can be an evaluation of just one body part to an evaluation of a multi-system or a thorough evaluation of an organ system.
a. Types of examinations
There are four kinds of examinations upon which E/M services are based upon:
• Problem Focused -- involves a limited evaluation of just the organ or part of body affected.
• Expanded Problem Focused -- involves a limited evaluation of the affected organ system or area as well as the connected or related areas or organ systems.
• Detailed -- this is an extended detailed examination of the body areas or organ systems affected as well as related or symptomatic organ systems…
Evaluation and Management Coding (E/M Code) The patient visited the clinic complaining of pain and redness to the left foot and with a history of diabetes. Following an assessment of the patient’s condition and his clinical history, he was diagnosed with cellulitis in addition to type 2 diabetes. Given the patient’s history of diabetes, he is at high risk of developing MRSA and/or osteomyelitis secondary to skin infection. The treatment and
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