1. How to Dissect an E&M Service
History and Physical
How to Dissect an E&M Service: History and Physical
PMI Online Education

2. S.O.A.P. S.O.A.P. Most reports follow the note format Recognize the
SOAP note format
Assign these components
History
Physical Exam
Medical
Decision-making
Most reports follow the
S.O.A.P.
note format
Coding an E&M service can be daunting at first glance. Most reports are dictated following the SOAP note format. Good abstraction begins with recognizing this format and assigning the history, physical examination, and medical decision making components to each section.

3. S O A P S.O.A.P. Chief complaint Patient history Review of systems
ubjective
Chief complaint
Patient history
Review of systems O
bjective
This tutorial will:
Explain abstraction process
Define the components
Physical examination
Lab data findings
Work performed to determine level of PE
Necessary for MDM A
ssessment
Consider the relationship like this:
Subjective: This includes the Chief Complaint, patient history, review of systems.
Objective: This represents the physical examination, lab data findings, and any work performed to determine the level of PE (physical examination).
Assessment: This portion gives the coder the number of diagnosis and the degree of mortality and morbidity. Both are necessary for the medical decision making component.
Plan: This often details the management options the physician will apply to this patient. This presents the final element for determining the level of medical decision making.
This tutorial will walk you through the abstraction process step by step and help you define the components.
Number of diagnosis
Degree of mortality and morbidity P
lan
Management options
Final element

4. HISTORY 99201 99202 99203 99204 99205 E&M Selection:
Page 1
HISTORY
E&M Selection:
99201
99202
99203
99204
99205
Detail elements pertinent to PFSH
Patient status: New
Place of service: Office/outpatient
Remaining complaints detail:
Personal history
Presenting diagnosis
Current management options
This statement gives the patient status, which is new, and the place of service, which can be considered office or outpatient. This narrows the E&M selection to just five. ( )
The remaining chief complaint details personal history, presenting diagnosis, and current management options. These help define the history and medical decision making components.
This information here details elements that are pertinent to Past, Family, and Social History.

5. Should be part of the intake paperwork for a new patient
Page 1
HISTORY
E&M Selection:
99201
99202
99203
99204
99205
While unremarkable, the Review of Systems (or ROS) are covered by this statement and should be part of the intake paperwork for a new patient. This completes the history component at a comprehensive level.
Should be part of the intake paperwork for a new patient

6. PHYSICAL Understand the elements required for the physical exam
Page 2
PHYSICAL
Understand the elements required for the physical exam
(vitals, general appearance, HEENT)
9 or more OS/BA
Make sure you understand the elements required for the physical exam. The vitals and general appearance remark represent two elements. The reference to “HEENT” covers 4 more: head, ears, eyes, nose, and throat.
The remaining narrative covers at least 9 more OS/BA (organ systems/body areas). This justifies a comprehensive level of PE (physical examination).

7. PHYSICAL Remember the glucose logs mentioned in the CC
Page 2
PHYSICAL
Gives the management options and test data to be reviewed by physician
Remember the glucose logs mentioned
in the CC
These diagnoses give the number of presenting problems in determining the level of risk
Make sure that you know the components of MDM. These diagnoses give the number of presenting problems in determining the level of risk. There are 2 chronic but stable issues mentioned here.
The plan gives the management options and test data to be reviewed by the physician. There are 3 separate test results to review and one referral. Remember the glucose logs mentioned in the CC. This equates to a moderate amount of data to review.

8. Risk of Mortality/Morbidity
While this patient has a
number of potential
serious issuses…
Level of Risk: Moderate
Overal Comlexity: Moderate
He is somewhat stable at this time
Finally, the risk of mortality/morbidity. While this patient has a number of potential serious issues, he is somewhat stable at this time. The appropriate level of risk should be moderate while the overall complexity of medical decision making should also be moderate.

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