The following chart outlines the various levels of history that you must document to report the corresponding E/M code. Note that history is just one E/M element that determines your code level. You must also document the appropriate examination and medical decision-making elements to justify reporting these codes.
A problem-focused history ( CPT 99201 ) includes:
Chief complaint
Brief history of present illness (one to three elements)
No review of systems or past, family or social history is required
An expanded problem-focused history (99202) includes:
Chief complaint
Brief history of present illness (one to three elements)
Problem-pertinent review of systems (one system)
No past, family, social history is required
A detailed history (99203) includes:
Chief complaint
Extended history of present illness (four or more elements, or three or more chronic or inactive conditions if 1997 Medicare E/M guidelines are being followed)
Problem-pertinent system review extended to include a review of a limited number of additional systems (two to nine systems)
Pertinent past, family, and/or social history directly related to the patient's problems (one or two areas of history)
A comprehensive history (99204, 99205) includes:
Chief complaint
Extended history of present illness
Review of systems that is directly related to the problem(s) identified in the history of the present illness plus a review of all additional body systems (more than 10 systems)
Complete past, family and social history (two or three history areas).