Definition of "Social History" and "Review of Systems" in E/M Guidelines

By W. Bruce Milliman, ND, and Eva Miller, ND (AMA - CPT/Editorial Panel/HCPAC, representing the AANP)

We are continuing our discussion on components of Evaluation and Management (E/M) codes. This article will cover: social history and review of systems. Next month we will discuss the relevance of time with regard to appropriate E/M coding. Then we will be ready to put it all together to help you distinguish the complexity of the visit so you can document and code the visit correctly. Reviewing and understanding the components as we have in the last 3 articles is essential to appropriately selecting the level of E/M services.

Social History
As written in CPT Professional Edition 2011
“An age appropriate review of past and current activities that includes significant information about:”
  • Marital status and/or living arrangements
  • Current employment
  • Occupational history
  • Use of drugs, alcohol and tobacco
  • Level of education
  • Sexual history
  • Other relevant social factors
Review of Systems
As written in CPT Professional Edition 2011
“An inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms that the patient may be experiencing or has experienced. For the purposes of the CPT code codebook the following elements of a system review have been identified:”
  • Eyes
  • Ears, nose, throat, mouth
  • Cardiovascular
  • Respiratory
  • Gastrointestinal
  • Genitourinary
  • Musculoskeletal
  • Integumentary
  • Neurological
  • Psychiatric
  • Endocrine
  • Hematologic/lymphatic
  • Allergic/immunologic
    “The review of systems helps define the problem, clarify the differential diagnosis, identify needed testing, or serves as baseline data on other systems that might be affected by any possible management options.”