What is the difference between 'problem-focused' and 'expanded problem-focused' E/M documentation?

• A. They differ in depth of history, exam, and medical decision making as defined by E/M guidelines
• B. They differ only in the time spent with the patient
• C. They differ by payer policy only
• D. They are the same

Answer: (A)

In E/M documentation, the difference is about how deeply you document the patient’s history, the exam, and the medical decision making. Problem-focused means you document only what’s needed to address the presenting problem—a limited history related to that problem, an exam focused on the affected area, and a straightforward, minimal level of medical decision making. Expanded problem-focused requires a fuller history (more elements related to the problem and its context) and a more thorough exam of the involved body area or systems, with a higher (but still not as extensive as detailed or comprehensive) level of medical decision making. Time can influence the level when counseling or coordination dominates, but the core distinction is the depth of history, examination, and MDM per the guidelines.