The Evaluation and Management (E/M) services are the most widely used codes in the Current Procedural Terminology (CPT) code set. This lesson explains the general documentation principles for the E/M history component and the requirements for the different levels of E/M services included in the 1995 and 1997 documentation guidelines for E/M services. The lesson will help the learner develop the skills necessary to identify each required element and accurately assign the level of history documented in E/M services. A current copy of the Current Procedural Terminology (CPT), Professional Edition, and the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services are strongly recommended to optimize your understanding of the content covered.
“This program has been approved for 0.5000 continuing education unit(s) for use in fulfilling the continuing education requirements of the American Health Information Management Association (AHIMA). Granting prior approval from AHIMA does not constitute endorsement of the program content or its program sponsor.”
This activity is approved for 0.5000 contact hours.
Section 1: Introduction
About This Course
Section 2: Overview
E/M Leveling Overview
Determining the E/M Service Level
Definition of History
Section 3: Chief Complaint
Definition: Chief Complaint
Chief Complaint Examples
Section 4: History of Present Illness (HPI)
Definition: History of Present Illness (HPI)
History of the Present Illness (HPI)
HPI Documentation Examples
Review, Part I
Review, Part II
Section 5: Review of Symptoms
Definition: Review of Systems (ROS)
Review of Systems (ROS)
ROS Documentation Examples
Section 6: Past, Family, Social History
Definition: Past, Family, Social History (PFSH)
PFSH Documentation Examples
Section 7: Determine the Extent of History
Determine the Extent of History
Section 8: Conclusion
Expert Reviewer: Andrei Besleaga, BS, RHIT
Sarah is a Subject Matter Expert/Writer for Relias's Revenue Cycle and Coding online education. Sarah is credentialed by AHIMA as a Certified Coding Specialist (CCS) and Certified Coding Specialist Physician-based (CCS-P), as well as an approved ICD-10-CM/PCS Trainer. She is also credentialed by AAPC as a Certified Professional Coding Instructor (CPC-I), a certified coder of physician/professional (CPC) and outpatient hospital services (COC), and a Certified Risk Adjustment Coder (CRC), with specialty certification in Evaluation and Management Services (CEMC). Sarah has extensive experience in both professional and facility ICD-10-CM/PCS, CPT and HCPCS coding, auditing, and revenue cycle management and as an educator of hospital and professional medical coding curriculum. She has served as Director of Physician Billing and Reimbursement for a regional health system, Manager of Coding and Compliance for a hospital and cancer center, and Business Manager of Physician Practices at a teaching hospital, as well as a coding auditor and consultant. Sarah has also authored coding textbooks and instructional resources.Disclosure: Sarah A. Serling, CCS, CPC, CRC, COC, CCS-P, CEMC, CPC-I, ICD-10-CM/PCS Trainer has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Expert Reviewer: Arletrice A. Watkins, MHA, RHIA
Andrei is a healthcare coding analyst in the CPT Education and Information Services Department at the American Medical Association, a staff writer for CPT Assistant, and a contributing author of the Principles of CPT Coding textbook. He has been a Registered Health Information Technician since 2009 and an active AHIMA member. He has gathered experience and developed skills by working in health insurance, at third-party payers, and in top-ranked national health care organizations. He completed an AAS in Health Information Technology from DeVry University in 2008 and a BS in Biology from Georgia Gwinnett College in 2015. In his spare time Andrei enjoys traveling, reading, playing the piano and the pipe organ.Disclosure: Andrei Besleaga, BS, RHIT has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
Arletrice is a senior healthcare coding analyst in the CPT Education and Information Services Department and staff writer for CPT Assistant. She supports and assists with other department projects on an as-needed basis, and she is also a contributing author of the Principles of CPT Coding. She has been with the AMA for over 14 years. She has been an educator since 2002 in health information technology (HIT) and is currently a health care administration adjunct instructor at an online university. She earned a BS in Health Information Administration from the University of Illinois at Chicago, IL, and a Masters of Healthcare Administration from the University of Phoenix, AZ. She is also certified as a registered health information administrator from the American Health Information Management Association (AHIMA), as well as an AHIMA-approved ICD-10 CM/ PCS trainer.Disclosure: Arletrice A. Watkins, MHA, RHIA has declared that no conflict of interest, Relevant Financial Relationship or Relevant Non-Financial Relationship exists.
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