Definition of "Family History," "History of Present Illness," and "Past History" in E/M Guidelines

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

In this article we will continue our discussion on the components of Evaluation and Management. Last month “New and Established patients” criteria and “Chief Complaint” were defined as reported in CPT Professional Edition. Today we will define "Family History," "History of Present Illness" and "Past History." We are still in the “S” (Subjective) section of documentation of a patient visit.
Family History
As written in CPT Professional Edition:
“A review of medical events in the patient’s family that includes significant information about:
  • The health status or cause of death of parents, siblings, and children
  • Specific diseases related to problems identified in the Chief Complaint or History of the Present Illness, and/or System Review.
  • Diseases of family members that may be hereditary or place the patient at risk.”
History of Present Illness
As written in CPT Professional Edition:
“A chronological description of the development of the patients present illness from the first sign and/or symptoms to the present. This includes a description of location, quality, severity, timing, context, modifying factors, and associated signs and symptoms significantly related to the presenting problem(s).”

Past History
As written in CPT Professional Edition:
“Review of the patients past experiences with illnesses, injuries and treatments that includes significant information about:
  • Prior major illnesses and injuries
  • Prior operations
  • Prior hospitalizations
  • Current medication
  • Allergies (eg, drug, food)
  • Age appropriated immunization status
  • Age appropriate feeding/dietary status”
Stay tuned next month for more on the components of E/M services.