Which two elements can be recorded by someone other than the provider performing the E/M service?

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Prepare for the AAPC CEMC Exam. Utilize flashcards and multiple-choice questions with detailed explanations and hints. Equip yourself for success!

The correct choice highlights the components of a patient’s medical history that can be gathered by someone other than the provider conducting the Evaluation and Management (E/M) service. The Review of Systems (ROS) and Past, Family, and Social History (PFSH) are both information elements that can be collected through questionnaires or interviews before the provider's interaction with the patient.

The ROS is a systematic review of various body systems, where the patient can report symptoms related to those systems. This information can be recorded by nursing staff or other healthcare personnel, facilitating a more efficient workflow and allowing the provider to focus on clinical assessment and examination during their time with the patient.

Similarly, the PFSH encompasses a brief history of the patient's past medical history, family medical history, and social history. This information can also be collected in advance of the provider’s evaluation, allowing for a comprehensive understanding of the patient’s background without necessitating the provider’s direct input at that moment.

The other components of the E/M service, specifically the History of Present Illness (HPI) and the Exam, generally require direct interaction with the provider. The HPI involves a detailed account of the patient’s current health issue, usually gathered through a dialogue that allows for probing questions

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