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History | Physical Examination | Decision Making | Quick Reference Tables


Physical Examination

Decision Making

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Welcome to the era of Documentation Guidelines (DG) for Evaluation and Management (E/M) Services as produced by the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS).

First approved in May 1995 and updated in 1997 and 2010, these guidelines were developed so the medical record will include the reason for the visit, relevant history, physical examination findings, and diagnostic results. From this information, a clinical impression and a plan for care can be formulated.

So far it sounds like a typical day in the office. What may be news to you is that Medicare has identified specific elements of the HISTORY, EXAMINATION, and DECISION MAKING process. You are required to select a code that correlates the level of history, exam and decision making that took place dung the visit, and is substantiated by the number of elements you document in the chart.

If someone comes in for a head cold, you will most likely examine them and diagnose a head cold, and then offer your best remedy. You can't code a high level visit even if you do an extensive examination. It's just a head cold!

If the patient comes in for a head cold and you detect a new hemiparesis, you may still list a head cold in the diagnosis. The additional history, exam, and decisions you make to test and treat the latter patient, oblige you to code a higher level for the visit. Below is an outline of what is expected when your code is compared to your chart.

There are four types of medical history you are most likely familiar with.. You must code the visit to reflect the type of history you took:

  • Problem-focused
  • Expanded Problem-focused
  • Detailed
  • Comprehensive

Each of these types of history must contain the:

Chief Complaint (CC). Reason for the visit in the patient's words.

History of the Present Illness (HPI). A chronological description incorporating the following eight elements; location, quality, severity, duration, timing, context, modifying factors, and associated symptoms of the patient's illness.

  • BRIEF HPI includes 1-3 elements
  • EXTENDED HPI should contain > 4 elements or the status of 3 chronic conditions

The history may incorporate:

Review of Systems (ROS). Inventory of these 13 body systems: constitutional, eyes, ears-nose-mouth-throat, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, integumentary, neurological, psychiatric, hematologic/lymphatic, allergic/immunologic.

  • PERTINENT contains responses for the affected system
  • EXTENDED contains responses for 2-9 systems
  • COMPLETE contains responses for >10 systems

Past history, family history, social history (PFSH). This should include:

1) illnesses, operations, injuries and treatments the patient has experienced; 2) any significant medical events or hereditary illness in the patient's family; 3) past or current activities of the patient.

  • PERTINENT contains one of the three
  • COMPLETE contains at least two

The CC, ROS and PFSH may be listed as separate elements or included in the HPI. The ROS and/or PFSH obtained during an earlier encounter does not need to be re-recorded if the physician reviews and updates the previous information. Your staff or the patient may complete any form for ROS or PFSH, but you must document a confirmation and note any changes to the information recorded by others.





Decision Making

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Physical Examination

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Physical Exam

The examination can concentrate on a single region, more than one region or take the form of a general multi-system examination. There are four types of medical examinations. You must code the visit to reflect the type of exam you conducted:

  • Problem Focused - limited exam of affected region.
  • Expanded Problem Focused - limited exam of affected region and additional, related region(s).
  • Detailed - extended exam of affected region and additional related region(s).
  • Comprehensive - general multi-system exam or complete single region and related region(s). 

There are 14 regions for examination and each contain elements:

Constitutional: BP, pulse, temp, RR, height, weight, appearance

Head and Face: inspection, palpation, salivary glands

Eyes: visual acuity, fields, conjunctivae, lids, pupils

Ears, Nose, Mouth, Throat: EAC's, TM's, mucosas

Neck: palpation, thyroid

Respiratory: respiratory effort, percussion, palpation, auscultation

Cardiovascular: palpation, auscultation, exam of pulses

Chest: inspection and palpation of breasts

Gastrointestinal: palpation of liver , spleen, masses, exam for tenderness

Genitourinary: (female or male)

Hematologic • Lymphatic • Immunologic

Musculoskeletal: range of motion , muscle strength and tone

Skin: inspection, palpation

Neurologic/Psychiatric: mental status, cranial nerves, reflexes, sensation

When a finding is abnormal it must be described: Simply identifying it as abnormal does not count!

A simple notation of normal is accepted for normal or negative findings.

Decision Making

These are the four types of medical decisions you make every day:

  • Straightforward - single diagnosis, no labs, minimal risk. (Tinea coporis, cold, insect bite)
  • Low Complexity - two problems or stable chronic problem, limited testing, low risk. (controlled HTN or DM, cystitis, allergic rhinitis)
  • Moderate Complexity - single acute systemic illness or chronic illness(es) with exacerbation. (colitis, pneumonitis, pyelonephritis)
  • High Complexity - single acute illness threatening function or chronic illness(es) with severe exacerbation. (TIA, sensory loss, MI, respiratory distress)

A senior reviewer from HCFA noted a possible weakness in the check-off format as used in our forms. "The physician could be slighted on scoring even though he or she has done a very comprehensive exam." So although the forms will guide you through the History and Examination components, the level of decision-making component is UP TO YOU. Here is where you must remember to document what you are thinking!


  1. DOCUMENT Diagnoses and Management: List your clinical impression or Diagnosis. If you are uncertain of the diagnosis, then list the differential diagnosis with "rule out" (R/O), "probable" or "possible." If the patient is seen for a chronic problem, add your impression of "improved," "controlled," "resolving," "resolved," "worsening," or "failing to change as expected." The second aspect is the plan or Management: List the treatment you propose. documenting medication, patient instructions, sub-specialist referral and proposed therapy. When you refer a patient jot down: who, what for, and where. Expanded diagnoses and additional management decisions will justify a higher CPT code.
  2. DOCUMENT Data: List the tests you did in the office, the tests you ordered, or the tests you reviewed. Initial and date a lab test or report when you discuss it with the patient. You don't need to transcribe the report to your progress note as long as that report resides in the patient chart. If you only have an oral report, then document the results and source in your note. If you review outside records or information from additional sources, EXPLAIN the data! The statement "old records reviewed" does not count! You must document what you determined from review of the additional records.
  3. Risk: Here is where you don't have to do much at all. The risk is inferred from the morbidity associated with the presenting problem and your decisions on treatment and testing. If someone needs an ice pack for a bump on the head, or a craniotomy for a subdural, the risk is implied.


When you need to code a visit for counseling take the history as usual, then document the total face-to-face time you spent with the patient and describe the the counseling. To code for this type of visit, you need to spend more than half of your time counseling the patient or family.

Sample Forms
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Copyright © June 8, 1998 Theodore Christou, MD, FACP