E/M vs. Eye codes -- Part 1 E/M

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KEY COMPONENT 1: History

The First Key Component, the History, contains four component parts. They are:

► Chief Complaint

► History of the Present Illness (HPI): location, duration, timing, quality, context, severity, modifying factors, associated signs and symptoms.

► Review of Systems (ROS)

► Past History, Family History, and Social History (PFSH).

KEY COMPONENT 2: Examination

KEY COMPONENT 3: Medical Decision Making

A stable glaucoma would be low risk; a glaucoma that is not in control and requires change of medicine would be moderate risk. A patient presenting with acute glaucoma is considered high risk.