Awareness : Frequently Asked Questions

Evaluation and Management (E/M) FAQs-Key Component History

Key Component-History:

  • Question: If my office uses an E/M questionnaire for the Past, Family and Social History (PFSH) and Review of Systems (ROS), is it mandatory that the physician sign and date the form?

    Answer: It is mandatory that the physician’s documentation clearly indicates that the forms have been reviewed by him/her, and that any follow-up on positive and pertinent negative responses is documented. Source

  • Question: Can I document the most clinically relevant systems and then say “all other systems reviewed are negative” in order to qualify for a complete (10 system) ROS?

    Answer: This would be allowed if all other systems were, indeed, reviewed and are negative, and if a complete ROS is medically necessary. Source

  • Question: If the patient’s medical record indicates that the PFSH is “non-contributing” with regard to the patient’s condition, does this documentation support that the PFSH was reviewed?

    Answer: If the record indicates that the patient’s past, family, and social history (PFSH) is “non-contributing,” it may be inferred that the practitioner did not ask the patient about his or her PFSH. However, if the practitioner has reviewed the patient’s PFSH, it should be documented in the medical record. Source

  • Question: Can I use the HPI elements to describe acute or chronic diseases? For example, if I say, “The patient is here to be evaluated for severe HTN discovered two weeks ago”, would I get credit for two HPI elements (severity, duration)?

    Answer: Yes, credit would be given as indicated.Source

  • Question: Do I get credit for negative HPI elements, e.g., if I ask the patient about modifying factors and say “no modifying factors are present” would I get credit for this HPI element?

    Answer:  No, credit is not given for negative responses regarding HPI elements. Source

  • Question: If I document allergies, do I get credit for an element of past medical history, or is this counted as part of the review of systems (Allergic/Immunologic) (or both)?

    Answer:  The single element of allergies would only be counted once (for either past medical history or review of systems). Source

  • Question: Can I use elements of History of Present Illness (HPI) as elements of Review of Systems (ROS) and have them both count, or is it one or the other? For example if the patient has chest pain which is “associated with shortness of breath” in the HPI, does this also count as an element of respiratory ROS?

    Answer:  The same element would only be counted once. In the example given, there are two different elements indicated (shortness of breath and chest pain), so this would count for both HPI and ROS, respectively.. Source