History and Physical Examination

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

Only a "medically appropriate history and/or examination" is 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 tables below compare required H&P elements in the current and new CPT code set for the office/outpatient E/M codes.

*Code 99201 was deleted in 2021 and is not included in this table.

**Codes 99211, 99417, and G2212 are not included in this table because H&P elements do not apply when reporting using total time to select a code.

Download the Office E/MT Coding Changes Guide (PDF)