About Sean Dyer, MD

M4 Clerkship Director
Department of Emergency Medicine
Cook County Health and Hospital System
Instructor, Department of Emergency Medicine
Rush Medical College

Trick of the Trade: Fishhook Removal Techniques

fishhookPenetrating fishhook injuries can be a common occurrence during the warm weather months. Initially, it is important to evaluate what type of fishhook was being used. How many and where are the barbs? What shape is it (treble hook, single hook)? The physical examination requires a thorough neurovascular exam and, if penetration depth is difficult to assess, radiographs should be utilized for further evaluation.

What approach do you use to remove these barbed fishhooks?


By |2021-05-15T09:30:49-07:00Jan 8, 2018|Trauma, Tricks of the Trade|

ED Charting and Coding: Review of Systems

review of systems medical-chart-canstockphoto13003631-ros

Editor’s Note (Jan 13, 2023): 

The new AMA CPT 2023 Documentation Guidelines have been published and the prior Review of Systems section is no longer incorporated into the billing and coding guidelines. See the ACEP FAQ page on the 2023 Emergency Department Evaluation and Management (E/M) Guidelines.

The Review of Systems (ROS) was the most frustrating aspect of charting as an intern. Documenting at least 10 elements from systems seemingly unrelated to the chief complaint took as long as a physical exam and was much harder to remember. For efficiency, many of us include any pertinent positives and negatives in the history of present illness (HPI) and use an ROS caveat such as “10/14 Review of Systems completed and is negative except as stated above in HPI (Systems reviewed: Const, Eyes, ENT, Resp, CV, GI, GU, MSK, Skin, Neuro)” or “A complete Review of Systems was obtained and is negative except as stated in HPI.

This obviates documenting 10 or more separate systems, but what if you’re at a site where the coders won’t accept a blanket phrase? Should you keep your lengthy HPI and then chart the same info again? Or can we devise a ROS that is at a minimum not redundant, and perhaps even helpful?

CMS Definition & Requirements

The ROS is “an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced”. CMS recognizes the following organ systems* for ROS (1995 E/M Documentation Guidelines, PDF):

  1. Constitutional
  2. Eyes
  3. Ears, Nose, Mouth, Throat
  4. Cardiovascular
  5. Respiratory
  6. Gastrointestinal
  7. Genitourinary
  8. Musculoskeletal
  9. Integumentary (skin and/or breast)
  10. Neurological
  11. Psychiatric
  12. Endocrine
  13. Hematologic/Lymphatic
  14. Allergic/Immunologic

*Organ systems: A complete ROS must document systems, not regions of the body. This is an important distinction, e.g. Eyes and ENMT count separately, but Head and HEENT don’t count.

You can document 4 types of ROS, depending on how many of the possible 14 systems are reviewed:

E/M LevelROS TypeSystems Reviewed
II/IIIProblem Pertinent1

Work Smarter, Not Harder: Resuscitating ROS

How do you make this section useful?

  • Offload pertinent positives and negatives from the HPI into ROS.
  • Organize your history with HPI first, then ROS, and PFSH last (mimicking how CMS arranges the E/M guidelines) so you can document a concise HPI statement and move directly to ROS. This will make your charting efficient, yet effective and billable.
  • Use the ROS as a cognitive backstop. As a junior resident documenting ROS, I often realized I had forgotten certain history questions, did not have enough information to exclude an item on my differential, or that something the patient said did not fit with the rest of the picture, prompting me to re-evaluate my differential.
  • Have a quick, rehearsed set of ROS questions to cover any systems not included in the history. For example: Fevers? Vision/hearing changes? Sore throat? Chest pain? Shortness of breath? Vomiting or diarrhea? Painful urination? Rashes? Joint pain or swelling? Numbness or tingling? Changes in mood? Heat or cold intolerance? Bleeding or bruising? Allergic reactions? Tailor this question set to your practice setting and specific patients.

Final Tips

  • One item– positive, negative, or normal– will suffice for each system.
  • If you use dot phrases or macros, have a 2-4 system ROS for most patients and a complete ROS for patients that will reach E/M level 5. Consider also having a separate pediatric ROS.
  • Always document at least 2 systems to prevent downcoding to an E/M level 2-3.
  • ROS can be obtained by ancillary staff or by patient questionnaire, as long as the physician reviews and discusses any pertinent positives or negatives with the patient. Be sure to notate this in your documentation: “I have reviewed the ROS questionnaire and discussed the pertinent positives and negatives with the patient.” Also, initial any physical forms, e.g. patient questionnaires, which you have reviewed.
  • A complete ROS can be a hybrid, listing pertinent positives and negatives by system, and then a notation indicating “All other systems are negative.”
  • Both caveats used in the introduction are valid examples per CMS. If you give a number of systems in your caveat, you must list that number of systems afterwards, so the second version is more straightforward.
By |2023-01-13T18:40:59-08:00Nov 2, 2016|Administrative|

ED Charting and Coding: History of Present Illness & Past Medical, Family, Social History

Editor’s Note (Jan 13, 2023): 

The new AMA CPT 2023 Documentation Guidelines have been published and the prior history and physical elements are no longer incorporated into the billing and coding guidelines. See the ACEP FAQ page on the 2023 Emergency Department Evaluation and Management (E/M) Guidelines.

medical chart history of present illnessRemember the “OPQRST” mnemonic? It stands for Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, Timing. Not only can it guide your history taking, but charting these descriptors also ensures you can code at an appropriate level. The patient’s history is the first example of the balance between essential information and over-documentation. It should be comprehensive, yet be chief-complaint focused [1]. Below, we outline the components of a thorough and billable history.


The history includes 4 elements:

  1. Chief complaint (CC)
  2. History of present illness (HPI)
  3. Review of systems (ROS)
  4. Past medical, family, and social history (PFSH)

A chief complaint is required for all levels of charting. The remaining three elements (HPI, ROS, PFSH) determine the type of history for the chart, as separated into 4 levels [2,3]:

  1. Problem Focused
  2. Expanded Problem Focused
  3. Detailed
  4. Comprehensive

The lowest common history level met by all elements determines the highest billable Evaluation and Management (E/M) level.

Remember “4-2-1” rule: 4 descriptors for HPI, 2 sections of PFSH, and 1 item per system for ROS guarantees a Comprehensive history.

E/M LevelHistory TypeHPIROSPFSH
IProblem Focused1-300
II/IIIExpanded Problem Focused1-310


If the HPI and ROS meet requirements for a Comprehensive History (E/M level 5) but the chart does not include any elements from the PFSH, this limits the history to Expanded Problem Focused. You can not bill higher than an E/M level 3.

Chief Complaint (CC)

Centers for Medicare & Medicaid Services definition:

“A concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter, usually stated in the patient’s own words.”

A clearly stated CC may be documented in a physician’s note or a triage note [2].

History of Present Illness (HPI)

The HPI discusses details of the CC and provides a chronological story, usually with 3-4 of the following descriptors [1,2]:

  • Location
  • Quality
  • Severity
  • Duration
  • Timing
  • Context
  • Modifying factors
  • Associated signs/symptoms

A Brief HPI (E/M levels 1-3) requires 1-3 descriptors, while an Extended HPI (E/M levels 4-5) requires ≥4 descriptors [2,3]. Note that E/M level 4-5 charts can still be concise.


The patient is a 34 y/o M presenting with chest pain (chief complaint) that is substernal (location), starting an hour prior to arrival (duration) while mowing the lawn (context), feels “like a pressure” (quality) that is intermittent (timing) and severe (severity), with associated nausea and diaphoresis (associated signs/symptoms).

This qualifies for Comprehensive, E/M Level 5 with 8 HPI descriptors.

Review of Systems (ROS)

Keep your eye out for our next post, where we will dive into the complexities of ROS.

Past Medical, Family, and Social History (PFSH)

Past Medical History (PMH) includes chronic diseases, past illnesses/injuries, and operations/treatments. Family History (FH) is a review of medical events including hereditary and non-hereditary disease. Social History (SH) is a review of pertinent age-appropriate current and past risks factors such as alcohol/tobacco/drug use, sexual history, employment, and education. You must document one specific item for a Detailed history (E/M level 4) and at least one item each in two areas for a Comprehensive history (E/M level 5) [2,3].

Example for Detailed History, E/M level 4

  • PMH: Hypertension, hyperlipidemia, diabetes mellitus. [Detailed, E/M level 4]

Example for Comprehensive History, E/M level 5

  • PMH:Hypertension, hyperlipidemia, diabetes mellitus
  • SH: smokes cigarettes 1 ppd

A common misconception is that listing two past medical problems (e.g. hypertension, diabetes) are still all counted as two items. They are instead all under one item (PMH). You still need to list an item from either the SH or FH to be eligible for E/M level 5. Thus this would drop the coding from a potential E/M level 5 down to a level 4.

The PMFH recorded by ancillary staff (e.g. tobacco use recorded at triage as part of the SH) counts as long as it is included in your documentation with a statement of review and confirmation [1]. Example: “Past medical, family, and social histories reviewed and verified by me.”

Additional Tips

  1. CC, ROS, and PFSH may be recorded by ancillary staff or via patient questionnaire, but you must document that you have confirmed this information with the patient [2,3].
  2. What if a patient is unconscious, intubated, or refuses to give a history? If a patient’s condition or circumstance limits acquisition of any history component, add a qualifier describing the limitation, e.g. cannot obtain due to encephalopathy, dementia, intubation, etc. This qualifier applies to all elements of history: HPI, ROS, and PFSH [2,3]
  3. Did you play detective and obtain a history through other sources? Get credit! As an alternative to the extended HPI (E/M level 5 HPI), you can discuss the status of at least 3 chronic or inactive conditions [1,2]

Example: Patient sent from nursing home for altered mental status. He is nonverbal at baseline, but per nursing staff and transfer records, his (1) urinary retention has been stable with Foley in place, he (2) has not missed any seizure medications, and (3) the staff has been controlling his blood glucose well.

A statement describing how and what additional history was obtained will add to the complexity of data review in your medical decision making (MDM), which will be detailed in a later post). The statement “Additional history obtained by family/extended care facility staff” without elaboration will not count [2].

Work Smarter, Not Harder

The elements above describe the minimum data for each level. It is important to include additional data as appropriate and to avoid potential down-coding; however, be cognizant of wasting time or space recording historical information which neither contributes to your thought process nor billing. Some items are relevant to many aspects of care: diabetes in the family, bleeding and clotting diatheses, smoking history, and illicit drug use are both PFSH and risk factors. A patient’s living situation is relevant for disposition. Do not include “not relevant” or “non-contributory” history as it does not contribute to billable documentation.

See the PV Card on ED Charting and Coding


  1. Guth T, Morrissey T. Medical Documentation and ED Charting. CDEM Curriculum. 2015. Accessed 30, 2016.
  2. 1997 Documentation Guidelines for Evaluation and Management Services (PDF). Centers for Medicare & Medicaid Services. Accessed Aug 30, 2016.
  3. Evaluation and Management Services Guidelines (PDF). Department of Health & Human Services: Centers for Medicare & Medicaid Services. Accessed Aug 30, 2016.

(c) Can Stock Photo

By |2023-01-13T18:35:53-08:00Sep 5, 2016|Administrative|

PV Card: Introduction to ED Charting and Coding

Editor’s Note (Jan 13, 2023): 

The new AMA CPT 2023 Documentation Guidelines have completely revamped how the billing and coding for Emergency Department charts is done. See the ACEP FAQ page on the 2023 Emergency Department Evaluation and Management (E/M) Guidelines.

ED charting and coding computer-charting-TEXT-canstockphoto17902161What makes a good chart? How do you write a good chart quickly? How about a good, efficient, billable chart? On average, residents and practicing physicians report they did not receive adequate training in charting and coding [1–3] and resident charts are more often down-coded due to documentation failures than those of attendings and PAs [4]. Thankfully, resident education in charting has improved over the past 15 years [5], and a little learning goes a long way to improve confidence [6] and competence [7].

In the spirit of #FOAMed, we would like to provide some pearls and pitfalls for EM documentation, starting with a PV card that addresses the basic elements of coding a chart. We hope it’s a handy on-shift reference.

What is a CPT code? What is an E/M level?

In order to uniformly bill for services provided, the American Medical Association (AMA) maintains a list of Current Procedure Terminology (CPT) codes. When you provide medical services to a patient, the chart is billed using a CPT code based on Evaluation & Management (E/M) levels 1-5 [8]. Most ED visits are billed as E/M levels 3-5. In order to objectively categorize a chart, Centers for Medicare & Medicaid Services (CMS) created a coding system to assign an E/M level.

What is the difference between a lower and higher E/M level chart?

Three essential elements determine the E/M level: history, physical exam, and medical decision making (MDM). Each of these components is evaluated by a set of guidelines and categorized by the documented elements of the history/physical exam and complexity of MDM. After evaluating each essential element separately, all three are considered in choosing an E/M level and CPT code that is billed. The complexity of your MDM should ultimately determine your E/M level, but under-charting in another area will limit you from billing an appropriately high E/M level.

On your next shift, take a second to review your charts. Could one additional word in the history of present illness (HPI) bump a level 3 up to a level 4? Did you mention your chart biopsy, even if it was just skimming the most recent discharge summary or yesterday’s note? The following PV card outlines the minimum elements needed from all 3 areas required to code specific E/M levels, and shows that a single word or phrase may be the difference in clarifying a higher level of care provided.

Keep an eye out for our follow-up posts. We’ll focus on individual sections of the chart (history, physical examination, MDM), specific diagnoses and special situations that require extra care when documenting.

Happy charting!


  1. Howell J, Chisholm C, Clark A, Spillane L. Emergency medicine resident documentation: results of the 1999 american board of emergency medicine in-training examination survey. Acad Emerg Med. 2000;7(10):1135-1138. [PubMed]
  2. Pines J, Braithwaite S. Documentation and coding education in emergency medicine residency programs: a national survey of residents and program directors. Cal J Emerg Med. 2004;5(1):3-8. [PubMed]
  3. Dawson B, Carter K, Brewer K, Lawson L. Chart smart: a need for documentation and billing education among emergency medicine residents? West J Emerg Med. 2010;11(2):116-119. [PubMed]
  4. Ardolic B, Weizberg M, Cambria B, et al. 362: Documentation and Coding Skills: Is There Adequate training in Emergency Medicine Residency? Ann Emerg Med. 2006;48(4):108.
  5. Heiner J, Dunbar J, Harrison T, Kang C. 426: Current Emergency Medicine Residency Education of Documentation, Coding, and Reimbursement: Fitting the Bill? Ann Emerg Med. 2010;56(3):137-138.
  6. Takacs M, Stilley J. 169: Billing and Coding Shift for Emergency Medicine Residents: A Win-Win-Win Proposition. Ann Emerg Med. 2015;66(4):60.
  7. Carter K, Dawson B, Brewer K, Lawson L. RVU ready? Preparing emergency medicine resident physicians in documentation for an incentive-based work environment. Acad Emerg Med. 2009;16(5):423-428.
  8. Evaluation and Management Services Guidelines. Dept of Health & Human Services: Centers for Medicare & Medicaid Services. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf. Published August 2015. Accessed July 24, 2016.
By |2023-01-13T18:42:49-08:00Aug 15, 2016|Administrative, ALiEM Cards|

A Starter’s Roadmap to EM Resources: Books, Websites, and Apps

Roadmap to EM Resources text-road-map-canstockphoto6514821With the start of the year, we welcomed a new group of faces into our respective residency programs. We can all still remember how daunting it was to tackle learning the immense volume of material to be a great emergency medicine physician. We have so many amazing resources, but no road maps for where to start. The purpose of this list is to help guide the new interns as well as to highlight some resources that even the more seasoned clinician may find useful.


By |2019-04-07T01:31:19-07:00Aug 3, 2016|Medical Education, Social Media & Tech|
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