American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

History and Examination

Documenting H&P for Office/Outpatient E/M Services

Beginning January 1, 2021, only a "medically appropriate history and/or examination" will be required for all office/outpatient E/M codes. The number of body systems/areas reviewed and examined need only be performed and documented when  medically necessary and clinically appropriate. This element of reporting was revised by CMS for Medicare patients in an effort to reduce documentation burden.

Additionally, for Medicare patients, billing practitioners do NOT need to re-enter information about a patient's chief complaint and history in the medical record that has already been entered by ancillary staff or the beneficiary. The billing practitioner may simply indicate in the medical record that such information was reviewed and verified. Note that this policy may be different for non-Medicare private payors.

The table below compares required H&P elements in the current and new CPT code set for the office/outpatient E/M codes.

CPT Code

H&P Elements
Prior to 2021

H&P Elements
Effective in 2021

New Patient Codes*

99202

Expanded problem focused history/examination

Medically appropriate history and/or examination for all codes

99203

Detailed history/examination

99204

Comprehensive history/examination

99205

Comprehensive history/examination

Established Patient Codes**

99212

Problem focused history/examination

99213

Expanded problem focused history/examination

99214

Detailed history/examination

99215

Comprehensive history/examination

*Code 99201 will be deleted in 2021 and is not included in this table.
**Codes 99211 and G2212 are not included in this table because H&P elements do not apply.