Is Documentation of HPI and Exam Necessary in Determining a level of E/M?

Question:

With the 2021 and 2023 Guideline changes, is it necessary to document an HPI and Exam when neither counts towards the level of service?

Answer:

As described in the most recent AMA E/M guidelines, documentation of a history of present illness (HPI) and an exam are no longer required to contribute to the level of an E/M service. Today, documentation of medical decision-making or time is the sole determinant supporting a level of E/M.  E/M documentation should include a medically appropriate history and examination. While the nature and extent of the history and exam are determined by the clinician, they add to the medical necessity of the visit and provide a more complete representation of the patient’s condition for continuity and coordination of care with other clinical providers.

*This response is based on the best information available as of 11/14/24.