The history component in E/M includes which of the following?

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The history component in Evaluation and Management (E/M) coding is a comprehensive element that includes several critical components to assess a patient's condition thoroughly. The correct answer encompasses the chief complaint, history of present illness (HPI), review of systems (ROS), and past family and social history (PFSH).

  • Chief Complaint: This is the primary reason the patient is seeking medical attention and helps to direct the clinical focus of the visit.

  • History of Present Illness (HPI): This part details the story behind the patient’s current health issues, including the onset, duration, symptoms, and prior treatments. It provides the necessary context that informs the clinician's decision-making process.

  • Review of Systems (ROS): This is a systematic approach to gather information about the patient's various body systems and screen for conditions that may not have been addressed with the chief complaint or HPI.

  • Past Family and Social History (PFSH): This element offers crucial insights into the patient's medical background, including the health of family members and lifestyle factors that could influence health outcomes.

Together, these components establish a solid foundation for medical decision-making and coding, ensuring that the provider is thoroughly informed about the patient's medical

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