BY

Mazhar Altaf

Outpatient E/M services have the same basic

components as inpatient E/M.
Below are the basic components:

History

Chief Complaint
History of Present Illness (HPI)
Review of Systems (ROS)
Past Medical, Family, Social History (PFSH)

Examination

Medical Decision-Making (MDM)

Number of diagnoses or management options

Amount and/or complexity of data reviewed or ordered
Risk of complications and/or morbidity or mortality

Time

Chief Complaints:Reason for the encounter

A subjective statement made by a patient describing the most significant or serious
symptoms or signs of illness or dysfunction that caused him or her to seek health care. It is used
most often in a health history.

History of Present Illness (HPI)

History of present illness (HPI) are consist on eight component these are,
1.
2.
3.
4.
5.
6.
7.
8.

Location
Severity
Timing
Modifying factors
Quality
Duration
Context
Associated signs and Symptoms

Review of Systems (ROS)

Main components for Review Of System are given below different components
are use according to the level of E/M Codes.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

Constitutional
Eyes
Ears, nose, mouth, throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Endocrine
Hematologic or Lymphatic
Allergic or immunologic

Past Medical, Family, Social History (PFSH)

1. Past Medical History
1. Current medications
2. Drug allergies
3. Prior surgeries
4. Prior hospitalizations
5. Prior major illnesses or injuries
6. Immunizations
2. Family History
1.
Health status or cause of death of near relatives

Parents

Siblings

Children
2.
Specific disease related to CC, HPI, ROS
3.
Hereditary diseases for which the patient is at risk

Past Medical, Family, Social History (PFSH)

3. Social History
1. Occupational history
2. Current employment
3. Level of education
4. Marital status or living arrangements
5. Sexual history
6. Habits
Nutritional status
Tobacco use
Alcohol use
Illicit Drug use

Four types of examination are usually used in evaluation and

management system those are.
1.

Problem Focused Type.

Limited to affected body area or organ system.

2.

Expanded Problem Focused Type.

Affected body area or organ system
Other symptomatic or related organ systems

3.

Detailed Type.
Extended examination of affected body areas
Other symptomatic or related organ systems

4.

Comprehensive Type.
Complete single system specialty examination or
Complete multi-system examination

PE has Body Areas

1.
2.
3.
4.
5.
6.
7.

Head
neck
Chest
Abdomen
Genitalia
Back
Each extremity

PE has Systems
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.

Constitutional
Eyes
Ears, nose, mouth, throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Endocrine
Hematologic or Lymphatic
Allergic or immunologic

Four types of MDM are usually used in evaluation and

management system those are.
1. Decision Making Type: Straightforward
Minimal number of diagnoses or management options
Minimal or no data to be reviewed
Minimal risk of complications, morbidity, mortality

2. Decision Making Type: Low Complexity

Limited number of diagnoses or management options
Limited amount or complexity of data to be reviewed
Low risk of complications, morbidity, mortality

3. Decision Making Type: Moderate Complexity

Multiple diagnoses or management options
Moderate amount or complexity of data to be reviewed
Moderate risk of complications, morbidity, mortality

4. Decision Making Type: High Complexity

Extensive diagnoses or management options
Extensive amount or complexity of data to be reviewed
High risk of complications, morbidity, mortality

Time Needed Criteria

If the physician document total time and suggests that counseling or coordinating care
dominates more than 50% of the encounter, time may determine the level of service.
Documentation may refer to: Prognosis, differential diagnosis, risks, benefits of treatment,
instructions, compliance, risk reduction or discussion with another health care provider.
If all answers are YES to the following queries, you may select a level of service based on time

Does the documentation reveal total time? (face to face in an outpatient setting)
Does the documentation describe the content of counseling or coordination of care?
Does the documentation reveal that more than half the time was counseling or coordinating care?

Level

Time

Level

Time

Level

Time

Level

Time

99201

10 min

99242

30 min

99213

15 min

99254

80 min

99202

20 min

99243

40 min

99214

25 min

99255

120min

99203

30 min

99244

60 min

99215

40 min

99204

45 min

99245

80 min

99251

20 min

99205

60 min

99211

5 min

99252

40 min

99241

15 min

99212

10 min

99253

55 min

New Patient

99201

99202

99203

99204

99205

Chief
Complaint

All Notes

All Notes

All Notes

All Notes

All Notes

HPI

1-3

1-3

ROS

Not Required

2-9

10+

10+

Not Required

Not Required

PE(System/Bod
y Area)

2-7(EPF)

2-7 (Det)

8+

8+

Medical Decision
Making

SF

SF

Low

Moderate

High

Time (Mins)

10

20

30

45

60

PFSH

(Time based visits document > 50% of time in counseling and/or coordination of care)
EPF= Expanded Problem Focused Exam Det.=Detailed Exam SF= Straightforward Decision
Making

Established

99211

99212

99213

99214

99215

Chief
Complaint

All Notes

All Notes

All Notes

All Notes

All Notes

HPI

Not Required

1-3

1-3

N/A

2-9

10+

N/A

N/A

2-7 (EPF)

2-7 (DET)

8+ (Comp)

SF

Low

Moderate

High

10

15

25

40

ROS
PFSH

Not Required
Not Required

PE(System/Bod
y Area)

Not Required

Medical Decision
Making

Not Required

Time (Mins)

EPF= Expanded Problem Focused Exam Det.=Detailed Exam SF= Straightforward Decision
Making

Office
Consultation

99241

99242

99243

99244

99245

Chief
Complaint

Established CC

Established CC

Established CC

Established CC

Established CC

HPI

1-3

1-3

ROS

Not Required

2-9

10+

10+

PFSH

Not Required

Not Required

PE(System/Bod
y Area)

2-7 (EPF)

2-7 (DET)

8+ (Comp)

8+ (Comp)

Medical Decision
Making

SF

SF

Low

Moderate

High

Time (Mins)

15

30

40

60

80

EPF= Expanded Problem Focused Exam Det.=Detailed Exam SF= Straightforward Decision
Making

Emergency
Services

99281

99282

99283

99284

99285

Chief
Complaint

Established CC

Established CC

Established CC

Established CC

Established CC

HPI

1-3

1-3

1-3

ROS

Not Required

2-9

10+

PFSH

Not Required

Not Required

Not Required

PE(System/Bo
dy Area)

1 (PF)

2-7 (EPF)

2-7 (EPF)

2-7 (Det)

8+ (Comp)

Medical Decision
Making

SF

Low

Moderate

Moderate

High

Time (Mins)

N/A

N/A

N/A

N/A

N/A

PF= Problem Focused EPF= Expanded Problem Focused Exam Det.=Detailed Exam SF=
Straightforward Decision Making

Inpatient
Consultation

99251

99252

99253

99254

99255

Chief
Complaint

Established CC

Established CC

Established CC

Established CC

Established CC

HPI

1-3

1-3

ROS

Not Required

2-9

10+

10+

PFSH

Not Required

Not Required

PE(System/Bo
dy Area)

1 (PF)

2-7 (EPF)

2-7 (Det)

8+ (Comp)

8+ (Comp)

Medical Decision
Making

SF

SF

Low

Moderate

High

Time (Mins)

20

40

55

80

110

PF= Problem Focused EPF= Expanded Problem Focused Exam Det.=Detailed Exam SF=
Straightforward Decision Making

Initial Hospital
Care

99221

99222

99223

Chief Complaint

All Notes

All Notes

All Notes

HPI

ROS

2-9

10+

10+

PFSH

PE(System/Body Area)

2-7 (DET)

8+

8+

Medical Decision Making

SF/Low

Moderate

High

Time (Mins)

30

50

70

EPF= Expanded Problem Focused Exam Det.=Detailed Exam SF=

Straightforward Decision Making

Subsequent
Follow-up Visit

99231

99232

99233

Chief Complaint

All Notes

All Notes

All Notes

HPI

1-3

1-3

ROS

Not Required

2-9

PFSH

Not Required

Not Required

PE(System/Body Area)

1 (PF)

2-7 (EPF)

2-7 (Det)

Medical Decision Making

SF/Low

Moderate

High

Time (Mins)

15

25

35

PF= Problem Focused EPF= Expanded Problem Focused Exam Det.=Detailed

Exam SF= Straightforward Decision Making

Observation
Services

99218

99219

99220

Chief Complaint

All Notes

All Notes

All Notes

HPI

ROS

2-9

10+

10+

PFSH

PE(System/Body Area)

2-7 (DET)

8+ Comp

8+ Comp

Medical Decision Making

SF/Low

Moderate

High

Time (Mins)

N/A

N/A

N/A

EPF= Expanded Problem Focused Exam Det.=Detailed Exam SF=

Straightforward Decision Making Comp=Comprehensive

Inpatient Care
Services

99234

99235

99236

Chief Complaint

All Notes

All Notes

All Notes

HPI

ROS

2-9

10+

10+

PFSH

PE(System/Body Area)

2-7 (DET)

8+ Comp

8+ Comp

Medical Decision Making

SF/Low

Moderate

High

Time (Mins)

N/A

N/A

N/A

EPF= Expanded Problem Focused Exam Det.=Detailed Exam SF=

Straightforward Decision Making Comp=Comprehensive