Complete Practice Resources, Inc.
Complete Practice Resources Presents:
Survival in the E/M Jungle:
E/M Coding for Community
Health Centers
Complete Practice Resources, LLC
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Slidell, LA 70452
855-ICD-10CM |CPTICDPros.com
Complete Practice Resources, LLC (CPR)
Complete Practice Resources, LLC was formed specifically to assist providers in addressing the ICD-10 transition.
We are dedicated to improving healthcare delivery by providing innovative healthcare information technology and
services. From clinical and patient access management to revenue cycle and health information management,
Complete Practice Resources delivers real-world solutions that assist healthcare professionals deliver outstanding
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experience and dedication to service have earned Complete Practice Resources the trust and loyalty of customers
at physician practices nationwide and at every U.S. Department of Veterans Affairs Medical Center in the United
States.
CPR…Simple solutions for a complex world
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Contents
Purpose of this workshop: ............................................................................................................................ 4
Course Objectives: ........................................................................................................................................ 4
Evaluation and Management Coding............................................................................................................ 5
Know the Rules ......................................................................................................................................... 5
Code Selection .............................................................................................................................................. 7
Composition and Discussion of the Key Components .............................................................................. 8
History ................................................................................................................................................... 8
Examination ........................................................................................................................................ 14
Medical Decision Making .................................................................................................................... 22
Medical Necessity ............................................................................................................................... 27
ICD-9 Codes ................................................................................................................................................. 28
References .................................................................................................................................................. 28
Coding Practice ........................................................................................................................................... 29
Sample Patient #1 – Power Point Example ............................................................................................. 29
Sample Patient #2 - Chronic Medical Conditions (Follow-up ) .............................................................. 30
Sample Patient #3 - Acute Cystitis & Diabetes Type II ................................................................................ 32
Sample Patient #4 - Asthma in a 5-year-old (ED Visit) ................................................................................ 33
Sample Patient #5 - Headache .................................................................................................................... 35
Attachment: Novitas E/M Form
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Purpose of this workshop:
To promote accurate E/M code selection through an understanding of E/M code components,
associated documentation elements, and common compliance missteps.
Course Objectives:
Awareness of the regulations
Know the appropriate use of the CPT categories
Understand the E/M components
Demonstrate E/M code assignment based on medical record evaluation
Recognize the differences between medical decision making and medical necessity
Understand the impact diagnosis codes can have on the E/M coding and reimbursement process
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Evaluation and Management Coding
Evaluation and Management (E/M) services are the most commonly used category of Current
Procedural Terminology (CPT) codes and can be the most challenging to those who are charged with
accurate code selection. In the late 1990s multiple efforts to design a set of documentation guidelines
that would serve as a code selection model for all going forward were written. Despite those efforts, and
the volumes that have been published about E/M services since then, the subject of appropriate code
selection remains a contentious one.
This document, and the accompanying presentation, reflects code selection instructions published by
the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS).
References to all source documents are provided.
Know the Rules
Managing coding compliance in this fast paced digital world is a challenge, and
having a sound understanding of the basics of any code set is a must. While the
basic subject matter is defined in three places: CPT, the 1995 Documentation
Guidelines and the 1997 Guidelines, additional rules may be imposed by payers and
employers. Clinicians, coders and billers must work together to ensure
documentation is appropriate and coding is compliant.
Documentation Guidelines
It has been almost 20 years since CMS, known as the Health Care Financing Administration (HCFA),
advised physicians there would be certain requirements made of medical records in order to justify the
E/M codes submitted for payment. Working in conjunction with the AMA and medical specialty
societies, CMS (HCFA) then developed and released the “Documentation Guidelines for Evaluation and
Management Services.” These guidelines established parameters for the history, exam and medical
decision making documentation required to justify coding and billing each level of E/M service.
Ultimately, two sets of guidelines were developed and neither was adopted in favor over the other.
They are now commonly referred to as the “1995 Documentation Guidelines” and the “1997
Documentation Guidelines.” Both remain as originally written and are now used by CMS and most other
payers as a measure of appropriate E/M code selection, although extensive additional clarification of
how they are to be applied often exists.
Payer Guidelines
CMS and its fiscal intermediaries publish extensive information detailing how E/M coding will be
evaluated; others are not so forthcoming making it difficult to settle coding and reimbursement
disputes. If at all possible, ascertain how major payers evaluate a level of service dispute prior to an
issue arising. And, as they say, “the best defense is a good offence.” Ensure your practice remains on the
offense by routinely following good documentation practices.
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Employer Guidelines
In addition to payer rules, it is important to know how your employer wishes to address coding
compliance. For instance, CMS publishes that it will honor both 1995 and 1997 Guidelines (if the
provider has stayed within the appropriate parameters), but some employers mandate the exclusive
application of one set of guidelines over the other for various valid reasons. It is important to know what
guidelines your organization follows.
Another example is compliance with published insurance specific mandates that are not in step with CPT
and the Documentation Guidelines. For example, everyone involved should understand process to be
followed when a payer such as Medicare and Medicaid has posted in writing that it will not recognize
consultation codes while other payers observe and pay consultation visits.
New Patients
Confusion often arises over the appropriate use of codes for new patients. New patients are those who
have not received any professional services from the physician/qualified health care professional or
another physician/qualified health care professional of the exact same specialty and subspecialty who
belongs to the same group practice, within the past three years. Providers on call, advanced practice
nurses and physician assistants are all considered as working in the exact same specialty/subspecialty as
the provider they are covering for or working under.
Professional services are defined by CPT as face-to-face services provided by physicians
and other qualified health care professionals who may report evaluation and
management services with a CPT code.
Consultation vs. Transfer of Care
CPT defines a consultation as a "type of service provided by a physician whose opinion or advice
regarding evaluation and/or management of a specific problem is requested by another physician or
other appropriate source." In March of 2006 the Office of Inspector General (OIG) announced that
approximately 75% of the Consultative E/M services billed in 2001, and allowed by Medicare, did not
meet program requirements resulting in $1.1 billion in improper payments. These services were more
than likely a transfer of care.
A transfer of care occurs when a physician or other qualified health care professional who is providing
management for some or all of a patient’s problems requests that another physician or other qualified
health care professional take over the care of some or all of the patient’s problems, and that provider
agrees to the transfer of care in advance. Under these circumstances an appropriate visit code such as
an office or inpatient visit code is reported by the accepting provider rather than a consultation code.
If, however, the decision to accept the transfer of care cannot be made without an initial consultation
evaluation, the accepting physician may report consultation codes. Documentation by both providers
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should reflect the nature and need for the consultation, but it is especially important for the consulting
provider’s documentation to clearly reflect the consultative circumstances to ensure the consultation
code will to stand up to payer scrutiny. Documentation should include the three R’s:
•
•
•
Reason for the consultation
Request for an opinion or advice
Report findings in writing from the consulting provider to the requesting physician
Code Selection
The E/M section is divided into various broad categories such as office visits, hospital visits, and
consultations. Most are further divided into subcategories such as new patient, established patient,
initial encounter and subsequent encounter. CPT specifies this division is important because the “nature
of work” varies by type of service, place of service, and the patient’s status.
Each subcategory is comprised of specific codes, the selection of which is most often based on three
“Key Components”: history, examination and medical decision making. Counseling, coordination of care,
nature of presenting problem and time are considered contributing factors, although a code may be
selected based on time when the record shows the visit is dominated by counseling and/or coordination
of care.
When counseling is the reason for the encounter or counseling time exceeds 50% of the visit, then time
is considered a component for level assignment of a code. The provider must document:
•
•
•
•
Total time of the visit
Measured by face-to-face time
Amount of time spent counseling
The nature of the counseling
If these requirements are met, then a level of service may be assigned based on time rather than the
key components.
Ultimately accurate representation of the service provided must be reflected in the provider’s
documentation for an appropriate code to be selected. The following sections provide a detailed review
of the E/M code components in the context of CPT definition and application of the documentation
guidelines.
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Composition and Discussion of the Key Components
History
Elements
Types of History
Chief Complaint
Problem focused
History of Present Illness
Expanded problem focused
Review of Systems
Detailed
Past (medical), Family, and Social
History
Comprehensive
Chief Complaint (CC)
CPT defines the CC as, “A concise statement describing the symptom, problem, condition, diagnosis, or
other factor that is the reason for the encounter, usually stated in the patient’s words.” The
documentation guidelines further stipulate that “the medical record should clearly reflect the chief
complaint.” However, the CC, review of systems, and past, family and social history may either be listed
separately or included in the description of the history or present illness.
History of Present Illness (HPI)
The HPI is a chronological description of the development of the present illness from the first sign
and/or symptom to the present. This includes a description of the following elements:
Location (example: left leg)
Quality (example: aching, burning, radiating pain)
Severity (example: 10 on a scale of 1 to 10)
Timing (example: constant or comes and goes)
Context (example: lifted large object at work)
Modifying factors (example: better when heat is applied)
Associated signs and symptoms (related to the presenting
problem) (example: numbness in toes)
Note: HPI definitions are provided by CMS Evaluation and Management Services Guide
The extent of HPI, review of systems, and past, family and/or social history that is obtained and
documented is dependent upon clinical judgment and nature of the presenting problem(s). Two types of
HPI are identified: brief and extended.
The 1995 Guidelines stipulate a brief HPI consists of one to three documented elements of the present
illness, and the extended HPI four or more elements of the present illness or associated comorbidities.
In 1997 the new Guidelines mandated that an extended HPI should describe at least four elements of
the present illness or the status of at least three chronic or inactive conditions. This is the only difference
between the history sections of the two sets of guidelines.
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Tip: Use caution when routinely using both sets of guidelines. The status of
three chronic conditions caveat is only applicable to the 1997 Guidelines and
should not be confused with the four elements of present illness or associated
comorbidities requirement of the 1995 Guidelines.
HPI Table
Brief HPI:
Extended HPI:
1995
Guidelines:
One to three documented elements of
the present illness
Four or more elements of the present
illness or associated comorbidities
1997
Guidelines:
One to three documented elements of
the present illness
At least four elements of the present
illness or the status of at least three
chronic or inactive conditions.
Review of Systems (ROS)
A ROS is an inventory of body systems obtained by asking the patient a series of questions to identify
signs and/or symptoms the patient may be experiencing or has experienced. Documentation should
reflect the patient’s positive responses and pertinent negatives. The Documentation Guidelines and CPT
recognize the following systems:
Constitutional symptoms (e.g., fever, weight loss)
Eyes
Ears, Nose, Mouth, Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary (skin and/or breast)
Neurological
Psychiatric
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic
The ROS may be recorded by ancillary staff or by the patient on a form provided; however, the provider
must make a notation supplementing or confirming review of the recorded information. If the provider
reviews information recorded earlier the documentation should reflect any new ROS, or note there has
been no change and identify the date and location of the previously recorded information.
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ROS Table
1995 & 1997 Descriptions
Problem
Pertinent
The patient's positive responses and pertinent negatives for the system related
to the problem should be documented.
Extended
The patient's positive responses and pertinent negatives for two to nine
systems should be documented.
Complete
A complete ROS inquires about the system(s) directly related to the problem(s)
identified in the HPI plus all additional body systems.
At least ten organ systems must be reviewed. Those systems with positive or
pertinent negative responses must be individually documented. For the
remaining systems, a notation indicating all other systems are negative is
permissible. In the absence of such a notation, at least ten systems must be
individually documented.
Past, Family, and/or Social History (PFSH)
The PFSH consists of a review of the following three areas:
Past history (the patient's past experiences with major illnesses, injuries and treatments, prior
operations and hospitalizations, current medications, allergies to drugs and food, age
appropriate immunization status, age appropriate feeding/dietary status.)
Family history (a review of medical events in the patient's family, including diseases which may
be hereditary or place the patient at risk)
Social history (an age appropriate review of past and current activities that include information
about marital status, employment and occupational history, use of drugs, alcohol and tobacco,
education, sexual history and other relevant social factors.)
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PFSH Table
1995 & 1997 Descriptions
Pertinent
A pertinent PFSH is a review of the history area(s) directly related to the
problem(s) identified in the HPI. At least one specific item from any of the three
history areas must be documented for a pertinent PFSH.
Complete
A complete PFSH is of a review of two or all three of the PFSH history areas,
depending on the category of the E/M service. A review of all three history
areas is required for services that by their nature include a comprehensive
assessment or reassessment of the patient. A review of two of the three
history areas is sufficient for other services.
At least one specific item from two of the three history areas must be
documented for a complete PFSH for the following categories of E/M services:
office or other outpatient services, established patient; emergency department;
subsequent nursing facility care; domiciliary care, established patient; and
home care, established patient.
At least one specific item from each of the three history areas must be
documented for a complete PFSH for the following categories of E/M services:
office or other outpatient services, new patient; hospital observation services;
hospital inpatient services, initial care; consultations; comprehensive nursing
facility assessments; domiciliary care, new patient; and homecare, new patient.
The patient’s history of present illness may ONLY be collected and recorded by the physician/qualified
healthcare professional, but the ROS and PFSH may be recorded by ancillary staff, or from a form
completed by the patient. Documentation Guidelines stipulate “To document that the physician
reviewed the information, there must be a notation supplementing or confirming the information
recorded by others.” A ROS or PFSH previously obtained may be used if the current documentation
references the date and location of previous information and updates that information or indicates
there has been no change.
Tip: Assess the type of information the provider has included throughout the note. Not
all information will be organized and easily identified such as that in a SOAP (subjective,
objective, assessment, and plan) note; rather data should be carefully scrutinized to
ascertain where it should be “counted” when selecting a level of service. For instance,
data relative to the history of present illness (HPI) and review of systems (ROS) is
subjective. Subjective information is anything asked of and answered, or offered by the
patient such as “I have been having trouble breathing for several days.” Observations of
the provider (including examination) are considered objective and are applied to
medical history, examination, or medical decision making depending on the context of
the note.
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Determining the Extent of History Obtained
The four types of history defined by CPT are defined below. Each includes a chief complaint:
Problem focused: brief HPI and problem pertinent system review
Detailed: extended HPI, problem pertinent system review extended to include a review of a
limited number of additional systems, pertinent past, family, and/or social history directly
related to the patient’s problems
Comprehensive: extended HPI, system review related to the problem indicated in the HPI
plus a review of all additional systems, complete past, family, and/or social history directly
related to the patient’s problems
History Table
History of Present
Illness (HPI)
Review of Systems
(ROS)
Past, Family, and/or
Social History (PFSH)
Type of History
Brief
N/A
N/A
Problem Focused
Brief
Problem Pertinent
N/A
Expanded Problem
Focused
Extended
Extended
Pertinent
Detailed
Extended
Complete
Complete
Comprehensive
To qualify for a given type of history, all three elements in the table must be met. A chief complaint must be
documented for each.
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There is no doubt that tracking the information required to select the HPI is cumbersome. Fortunately
there are many aids to assist you. The following is an excerpt from the MS part B Fiscal Intermediary,
Novitas Solutions.
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Examination
The levels of E/M services are based on four types of examination that are defined by CPT and both sets
of Guidelines (except as noted) as follows:
Type of Examination
Description
Problem Focused
A limited examination of the affected body area
or organ system.
Expanded Problem Focused
A limited examination of the affected body area
or organ system and other symptomatic or
related organ system(s).
Detailed
An extended examination of the affected body
area(s) and other symptomatic or related organ
system(s).
Comprehensive
1995: A general multi-system examination or
complete examination of a single organ system.
1997: A general multi-system examination or
complete examination of a single organ system
and other symptomatic or related body area(s)
or organ system(s).
The Guidelines differ extensively with respect to the parameters required to achieve each type of exam.
However there is agreement on several documentation related issues:
Specific abnormal and relevant negative findings of the examination of the affected or
symptomatic body area(s) or organ system(s) should be documented.
A notation of "abnormal” without elaboration is insufficient.
Abnormal or unexpected findings of the examination of the unaffected or asymptomatic body
area(s) or organ system(s) should be described.
A brief statement or notation indicating "negative" or "normal" is sufficient to document normal
findings related to unaffected area(s) or asymptomatic organ system(s).
The extent/content of the exam should be based on clinical judgment and the nature of the
presenting problem.
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1995 Examination Guidelines
The 1995 Guidelines define the problem focused examination as a limited examination of the affected
body area or organ system and indicate the general multi-system examination should include eight or
more of the 12 organ systems, but are very vague in the expanded problem focused and detailed
requirements:
•
Problem Focused -- a limited examination of the affected body area or organ system.
•
Expanded Problem Focused -- a limited examination of the affected body area or organ
system and other symptomatic or related organ system(s).
•
Detailed -- an extended examination of the affected body area(s) and other symptomatic or
related organ system(s).
•
Comprehensive -- a general multi-system examination or complete examination of a single
organ system. The medical record for a general multi-system examination should include
findings about 8 or more of the 12 organ systems.
In addition to the documentation guidelines outlined above, the 1995 Guidelines stipulate a
comprehensive general multi-system exam should include documentation related to 8 to 12 organ
systems (while body areas may be documented; only organ systems comprise a comprehensive exam.)
Using the definitions provided an examination that includes two to seven body areas or
organ systems can either be expanded problem focused or detailed. The difference is the
detail in which the examined systems are described, i.e. limited vs. extended. Without
precise criteria, the decision as to whether an exam is extended or not rests with the coder
or examiner.
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1995 examination body areas and organ systems:
Body Area
Organ Systems
Head, including the face
Constitutional (e.g., vital signs, general appearance)
Neck
Eyes
Chest, including breasts and axillae
Ears, nose, mouth, and throat
Abdomen
Cardiovascular
Genitalia, groin, buttocks
Respiratory
Back, including spine
Gastrointestinal
Each extremity
Genitourinary
Musculoskeletal
Skin
Neurologic
Psychiatric
Hematologic/lymphatic/immunologic
The following excerpt from Novitas Solutions demonstrates how the 1995 exam Guidelines are applied.
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1997 Examination Guidelines
The 1997 Guidelines saw a significant expansion of the examination criteria. This set of guidelines offers
a bullet counting system that includes a multi-system exam as described previously, and various single
organ system specialty exams. As a comparison, we will look at only the multi-system examination.
Complete details on all of the 1997 examinations can be found in the 1997 Guidelines via the link
provided in the reference section of the workbook.
To qualify for a given level of multi-system examination, the following content and documentation
requirements are to be met:
Level of Exam
Perform and Document
Problem Focused
One to five elements identified by a bullet.
Expanded Problem
Focused
At least six elements identified by a bullet.
Detailed
At least two elements identified by a bullet from each of six areas/systems OR at
least twelve elements identified by a bullet in two or more areas/systems.
Comprehensive
Perform all elements identified by a bullet in at least nine organ systems or body
areas and document at least two elements identified by a bullet from each of nine
areas/systems.
1997 General Multisystem Exam Elements
System/Body
Elements of Examination
Area
Constitutional
• Measurement of any three of the following seven vital signs: 1) sitting or
standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity,
4) respiration, 5) temperature, 6) height, 7) weight (May be measured and
recorded by ancillary staff)
• General appearance of patient (e.g., development, nutrition, body habitus,
deformities, attention to grooming)
Eyes
• Inspection of conjunctivae and lids
• Examination of pupils and irises (e.g., reaction to light and accommodation, size
and symmetry)
• Ophthalmoscopic examination of optic discs (e.g., size, C/D ratio, appearance)
and posterior segments (e.g., vessel changes, exudates, hemorrhages)
Ears, Nose, Mouth
and Throat
•
•
•
•
•
•
External inspection of ears and nose (e.g., overall appearance, scars, lesions,
masses)
Otoscopic examination of external auditory canals and tympanic membranes
Assessment of hearing (e.g., whispered voice, finger rub, tuning fork)
Inspection of nasal mucosa, septum and turbinates
Inspection of lips, teeth and gums
Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates,
tongue, tonsils and posterior pharynx
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1997 General Multisystem Exam Elements, continued
System/Body
Elements of Examination
Area
Neck
Examination of neck (e.g., masses, overall appearance, symmetry, tracheal
position, crepitus)
• Examination of thyroid (e.g., enlargement, tenderness, mass)
• Assessment of respiratory effort (e.g., intercostal retractions, use of accessory
muscles, diaphragmatic movement)
• Percussion of chest (e.g., dullness, flatness, hyperresonance)
• Palpation of chest (e.g., tactile fremitus)
• Auscultation of lungs (e.g., breath sounds, adventitious sounds, rubs)
• Palpation of heart (e.g., location, size, thrills)
• Auscultation of heart with notation of abnormal sounds and murmurs
Examination of:
• carotid arteries (e.g., pulse amplitude, bruits)
• abdominal aorta (e.g., size, bruits)
• femoral arteries (e.g., pulse amplitude, bruits)
• pedal pulses (e.g., pulse amplitude)
• extremities for edema and/or varicosities
• Inspection of breasts (e.g., symmetry, nipple discharge)
• Palpation of breasts and axillae (e.g., masses or lumps, tenderness)
• Examination of abdomen with notation of presence of masses or tenderness
• Examination of liver and spleen
• Examination for presence or absence of hernia
• Examination (when indicated) of anus, perineum and rectum, including
sphincter tone, presence of hemorrhoids, rectal masses
• Obtain stool sample for occult blood test when indicated
•
Respiratory
Cardiovascular
Chest (Breasts)
Gastrointestinal
(Abdomen)
Genitourinary
Male
•
•
•
Examination of the scrotal contents (e.g., hydrocele, spermatocele, tenderness
of cord, testicular mass)
Examination of the penis
Digital rectal examination of prostate gland (e.g., size, symmetry, nodularity,
tenderness)
Female Pelvic examination (with or without specimen collection for smears and cultures),
including:
•
•
•
•
•
•
Examination of external genitalia (e.g., general appearance, hair distribution,
lesions) and vagina (e.g., general appearance, estrogen effect, discharge,
lesions, pelvic support, cystocele, rectocele)
Examination of urethra (e.g., masses, tenderness, scarring)
Examination of bladder (e.g., fullness, masses, tenderness)
Cervix (e.g., general appearance, lesions, discharge)
Uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent
or support)
Adnexa/parametria (e.g., masses, tenderness, organomegaly, nodularity)
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1997 General Multisystem Exam Elements, continued
System/Body
Elements of Examination
Area
Lymphatic
•
•
•
•
•
Palpation of lymph nodes in two or more areas:
Neck
Axillae
Groin
Other
Musculoskeletal
•
•
Examination of gait and station
Inspection and/or palpation of digits and nails (e.g., clubbing, cyanosis,
inflammatory conditions, petechiae, ischemia, infections, nodes)
Examination of joints, bones and muscles of one or more of the following six areas:
1) head and neck; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper
extremity; 5) right lower extremity; and 6) left lower extremity. The examination
of a given area includes:
•
•
•
•
Inspection and/or palpation with notation of presence of any
misalignment, asymmetry, crepitation, defects, tenderness, masses,
effusions
Assessment of range of motion with notation of any pain, crepitation or
contracture
Assessment of stability with notation of any dislocation (luxation),
subluxation or laxity
Assessment of muscle strength and tone (e.g., flaccid, cog wheel, spastic)
with notation of any atrophy or abnormal movements
Skin
•
•
Inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers)
Palpation of skin and subcutaneous tissue (e.g., induration, subcutaneous
nodules, tightening)
Neurologic
•
•
•
Test cranial nerves with notation of any deficits
Examination of deep tendon reflexes with notation of pathological reflexes
(e.g., Babinski)
Examination of sensation (e.g., by touch, pin, vibration, proprioception)
•
Description of patient’ s judgment and insight
Psychiatric
Brief assessment of mental status including:
•
•
•
orientation to time, place and person
recent and remote memory
mood and affect (e.g., depression, anxiety, agitation)
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The following excerpt from Novitas Solutions demonstrates how the 1997 Exam Guidelines are applied.
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Medical Decision Making
The levels of E/M services recognize four types of medical decision making (straight-forward, low
complexity, moderate complexity and high complexity). Medical decision making refers to the
complexity of establishing a diagnosis and/or selecting a management option as measured by:
•
•
•
the number of possible diagnoses and/or the number of management options that must be
considered,
the amount and/or complexity of medical records, diagnostic tests, and/or other information
that must be obtained, reviewed and analyzed, and
the risk of significant complications, morbidity and/or mortality, as well as comorbidities,
associated with the patient's presenting problem(s), the diagnostic procedure(s) and/or the
possible management options.
The following table demonstrates the progression of the elements associated with each level of medical
decision making. To qualify for a given type of medical decision making, two of the three elements in the
table must be either met or exceeded. Each of the elements will be discussed further in the sections that
follow the table.
CPT stipulates that comorbidities/underlying diseases are not considered in selecting a
level of E/M service unless their presence significantly increases the complexity of the
medical decision making.
Number of diagnoses
or management
options
Minimal
Limited
Multiple
Extensive
Amount and/or
complexity of data to
be reviewed
Minimal or None
Limited
Moderate
Extensive
Risk of complications
and/or morbidity or
mortality
Minimal
Low
Moderate
High
Type of decision
making
Straightforward
Low Complexity
Moderate
Complexity
To qualify for a given type of medical decision making, two of three elements must be met or exceeded.
Number of Diagnoses or Management Options
The number of possible diagnosis and/or management options is based on the number and types of
problems addressed during the encounter, the complexity of establishing a diagnosis, and the
management decisions a provider makes during the encounter.
The guidelines offer additional clarification with respect to management options offering that decision
making for a diagnosed problem is generally easier than for an identified but undiagnosed problem, and
problems that are improving or resolving are less complex than those that are getting worse or failing to
change as expected. An indicator of the number of possible diagnoses may be the number and type of
diagnostic tests, while the need to seek advice from others may indicate the complexity of diagnostic or
management problems.
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With respect to diagnosis and management options documentation should also reflect an assessment,
clinical impression or diagnosis, and indicate whether or not the diagnosis is established. An established
diagnosis should be described as: improved, well controlled, resolving or resolved; or, inadequately
controlled, worsening, or failing to change as expected. A problem for which no diagnosis has been
established may be stated as a differential diagnosis or possible, probable, rule out, etc.
Any initiation or change of treatment should be documented and the record should reflect to whom or
where a referral or consultation is made and from whom advice is requested.
Amount and/or Complexity of Data to be reviewed
The amount and complexity of data to be reviewed is based on the types of diagnostic testing ordered
or reviewed. Complexity is increased if a decision is made to obtain and review old medical records
and/or obtain history from sources other than the patient. Discussion of contradictory or unexpected
test results with the performing or interpreting physician is also an indicator of data complexity, as is the
personal review of an image, tracing, or specimen by the ordering provider to supplement information.
Documentation should clearly reflect:
•
•
•
•
Diagnostic service(s) ordered, and any review of these services
A decision to obtain old records or additional history from another as well as any associated
findings (a notation old records reviewed, or additional history obtained is insufficient)
Discussion of the results of laboratory and other diagnostic tests with interpreting providers
Direct visualization and independent interpretation of an image, tracing or specimen
Risk of Significant Complications, Morbidity, and/or Mortality
Risk of significant complications, morbidity and/or mortality as based on the risks associated with the
presenting problem(s), the diagnostic procedure(s), and the possible management options.
Document each of the following as appropriate:
•
•
•
•
Comorbidities/underlying diseases or other factors that increase the risk of complications,
morbidity, and/or mortality
Surgical or invasive diagnostic procedures that are ordered, planned, or scheduled at the time of
the encounter
Surgical or invasive diagnostic procedures that are performed at the time of the encounter
A referral for or decision to perform a surgical or invasive diagnostic procedure on an urgent
basis
The guidelines each include the following Table of Risk to assist in determining the risk of significant
complications, morbidity, and/or mortality is minimal, low, moderate, or high. The table includes
examples rather than absolute measures because the determination of risk is complex. The assessment
of risk of the presenting problem(s) is based on the risk related to the disease process anticipated
between the present encounter and the next. The assessment of risk of diagnostic procedures and
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management options is based on the risk during and immediately following any procedures or
treatment. The highest level of risk in any one category (presenting problem(s), diagnostic procedure(s),
or management options) determines the overall risk.
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Table of Risk
Level of
Risk
Presenting Problem(s)
Diagnostic Procedure(s) Ordered
Management Options Selected
Minimal
One self-limited or minor
problem, e.g., cold, insect bite,
tinea corporis
Rest
Gargles
Elastic bandages
Superficial dressings
Low
Two or more self-limited or
minor problems
One stable chronic illness, e.g.,
well controlled hypertension,
non-insulin dependent
diabetes, cataract, BPH
Acute uncomplicated illness or
injury, e.g., cystitis, allergic
rhinitis, simple sprain
Moderate
One or more chronic illnesses
with mild exacerbation,
progression, or side effects of
treatment
Two or more stable chronic
illnesses
Undiagnosed new problem with
uncertain prognosis, e.g., lump
in breast
Acute illness with systemic
symptoms, e.g., pyelonephritis,
pneumonitis, colitis
Acute complicated injury, e.g.,
head injury with brief loss of
consciousness
One or more chronic illnesses
with severe exacerbation,
progression, or side effects of
treatment
Acute or chronic illnesses or
injuries that pose a threat to life
or bodily function, e.g., multiple
trauma, acute MI, pulmonary
embolus, severe respiratory
distress, progressive severe
rheumatoid arthritis, psychiatric
illness with potential threat to
self or others, peritonitis, acute
renal failure
An abrupt change in neurologic
status, e.g., seizure, TIA,
weakness, sensory loss
Laboratory tests requiring
venipuncture
Chest x-rays
EKG/EEG
Urinalysis
Ultrasound, e.g.,
echocardiography
KOH prep
Physiologic tests not under
stress, e.g., pulmonary function
tests
Non-cardiovascular imaging
studies with contrast, e.g., barium
enema
Superficial needle biopsies
Clinical laboratory tests requiring
arterial puncture
Skin biopsies
Physiologic tests under stress,
e.g., cardiac stress test, fetal
contraction stress test
Diagnostic endoscopies with no
identified risk factors
Deep needle or incisional biopsy
Cardiovascular imaging studies
with contrast and no identified
risk factors, e.g., arteriogram,
cardiac catheterization
Obtain fluid from body cavity, e.g.
lumbar puncture, thoracentesis,
culpocentesis
Cardiovascular imaging studies
with contrast with identified risk
factors
Cardiac electrophysiological tests
Diagnostic Endoscopies with
identified risk factors
Discography
Elective major surgery (open,
percutaneous or endoscopic)
with identified risk factors
Emergency major surgery
(open, percutaneous or
endoscopic)
Parenteral controlled
substances
Drug therapy requiring
intensive monitoring for toxicity
Decision not to resuscitate or
to de-escalate care because of
poor prognosis
High
Over-the-counter drugs
Minor surgery with no identified
risk factors
Physical therapy
Occupational therapy
IV fluids without additives
Minor surgery with identified
risk factors
Elective major surgery (open,
percutaneous or endoscopic)
with no identified risk factors
Prescription drug management
Therapeutic nuclear medicine
IV fluids with additives
Closed treatment of fracture or
dislocation without
manipulation
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The following excerpt from Novitas Solutions demonstrates how the Medical Decision Making Guidelines are applied.
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Medical Necessity
Medical necessity is often confused with Medical Decision Making. It is a method of measuring what is
necessary and appropriate with respect to medical services, including but not limited, to E/M services,
and various diagnostic tests.
Medical necessity from a payer’s perspective is not the same as that of a provider. Third party payers
require the following steps in establishing medical necessity and analyze documentation to determine if
it establishes:
•
•
Knowledge of the emergent nature or severity of the patient’s complaint or
condition
All facts regarding signs, symptoms, complaints, or background facts describing the
reason for the service
They often look to the nature of the presenting problem as a measure of the expected services. For
instance, it would be unlikely for a patient who presents with the complaint of an ingrown toenail to
require a comprehensive history and comprehensive examination.
CMS describes medical necessity from a documentation perspective in the following manner:
“Medical necessity of a service is the overarching criterion for payment in addition to the
individual requirements of a CPT code. It would not be medically necessary or appropriate to
bill a higher level of evaluation and management service when a lower level of service is
warranted. The volume of documentation should not be the primary influence upon which a
specific level of service is billed. Documentation should support the level of service reported.
The service should be documented during, or as soon as practicable after it is provided in
order to maintain an accurate medical record.”
-CMS Claims Processing Manual, Chapter 12, Section 30.6.1
Payment is limited by CMS to services that are deemed “reasonable and necessary”:
“No payment may be made under Part A or Part B for any expenses incurred for items or
services which…are not reasonable and necessary for the diagnosis or treatment of an illness
or injury or to improve the functioning of a malformed body member.”
-Section 1862 (A)(1)(A) of the Social Security Act
To a provider, medical necessity is black and white. If a patient’s condition warrants a
service, it’s medically necessary. A provider, when denied payment for an EKG by a payer
based on medical necessity, might respond to an inquiry,
“Of course the patient needed an EKG! If he didn’t, I wouldn’t have ordered it!”
In actuality the denied claim probably didn’t do a satisfactory job of painting an accurate picture.
Without reviewing a record, a payer may determine a claim doesn’t meet medical necessity. This is
often because the information included on the submitted claim did not demonstrate the need for the
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service(s) provided. At a minimum, the diagnosis code must support the CPT code, and the combination
of the two must make sense. In other words, the codes must tell the story with as much detail as
possible or the claim may be denied or delayed for review.
While payer reviews and denials are inevitable, medical necessity and other inquiries are generally
resolved by providing the associated documentation. Consistent compliance in observing the coding and
documentation guidelines will ensure your practice is as prepared as possible to provide the
documentation and favorably resolve these matters.
ICD-9 Codes
Not only is it important to document all conditions managed during a visit to the standards defined
within the guidelines, it is important to accurately report the corresponding diagnosis code(s). The
Federal Register (March 1994) directs, “Code the condition to the highest degree of certainty for that
encounter/visit to reflect symptoms, signs, abnormal test results or other reasons for the visit.”
When selecting diagnosis codes always select and code first, the condition, sign, or symptom, that
describes most important reason for the care provided. This is the primary diagnosis. It should be
followed by the conditions addressed and documented in order of importance. Code signs and
symptoms in the absence of a definitive diagnosis; never code conditions listed as probable, possible, or
rule out and avoid unspecified codes whenever possible.
Finally, be certain that all diagnosis codes are appropriately linked to each CPT code reported, and most
importantly…………
THINK IN INK
References
1995 and 1997 Official Guidelines and Evaluation and Management Service Guide:
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNEdWebGuide/EMDOC.html
Medical necessity reference from the internet claims processing manual:
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf
Novitas Solutions:
https://www.novitas-solutions.com/em/index.html
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Coding Practice
Sample Patient #1 – Power Point Example
HPI: Patient is a 13 year old complaining of ear pain in his left ear for two days. He describes the pain as
a 7 on a scale of 10. Mom states this is the third time this year. Aspirin reduces the pain, but does not
alleviate it.
ROS: Patient indicates there is no pain in the right ear and has no coughing or throat pain.
PMH: Patient has been healthy except for the two episodes of otitis media not associated with
respiratory infections. He received amoxicillin and both episodes resolved without issue.
EXAM
HEENT: Normocephalic, PEERLA, occular vessels normal. TMs deep red, dull, landmarks obscured, full
bilaterally. Post auricular and submandibular nodes on left are palpable and slightly tender.
Abdomen: Soft, rounded.
Assessment:
Chronic Otitis Media: Bilateral chronic otitis media due to a penicillin resistant organism.
Plan:
Prescription for 10 days of Augmentin 99; follow-up in 2 weeks. Consider ENT referral.
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Sample Patient #2 - Chronic Medical Conditions (Follow-up )
Reason For Visit: Follow-up evaluation and management of chronic medical conditions.
HPI: Follow-up evaluation and management of chronic medical conditions. Congestive heart failure,
stable on current regimen. Diabetes type II, A1c improved with increased doses of NPH insulin.
Hyperlipidemia, chronic renal insufficiency, and arthritis.
The patient has been doing quite well since he was last seen. He comes in today with his daughter. He
has had no symptoms of CAD or CHF. He had followup with Dr. X and she thought he was doing quite
well as well. He has had no symptoms of hyperglycemia or hypoglycemia. He has had no falls. His right
knee does pain him at times and he is using occasional doses of Tylenol for that. He wonders whether he
could use a knee brace to help him with that issue as well. His spirits are good. He has had no
incontinence. His memory is clear, as is his thinking.
Medications:
1. Bumex - 2 mg daily.
2. Aspirin - 81 mg daily.
3. Lisinopril - 40 mg daily.
4. NPH insulin - 65 units in the morning and 25 units in the evening.
5. Zocor - 80 mg daily.
6. Toprol-XL - 200 mg daily.
7. Protonix - 40 mg daily.
8. Chondroitin/glucosamine - no longer using.
Examination:
Weight 240, blood pressure by nurse 160/80, by me 140/78, pulse 91 and regular, and O2 saturation
94%. He is afebrile. JVP is normal without HJR. CTAP. RRR. S1 and S2. Aortic murmur unchanged.
Abdomen: Soft, NT without HSM, normal BS. Extremities: No edema on today's examination. Awake,
alert, attentive, able to get up on to the examination table under his own power. Able to get up out of a
chair with normal get up and go. Bilateral OA changes of the knee.
Labs:
Creatinine 1.7, which was down from 2.3. A1c 7.6 down from 8.5. Total cholesterol 192, HDL 37, and
triglycerides 487.
Assessments:
1. Congestive heart failure, stable on current regimen. Continue.
2. Diabetes type II, A1c improved with increased doses of NPH insulin. Doing self-blood glucose
monitoring with values in the morning between 100 and 130. Continue current regimen. Recheck A1c on
return.
3. Hyperlipidemia, at last visit, he had 3+ protein in his urine. TSH was normal. We will get a 24-hour
urine to rule out nephrosis as the cause of his hypertriglyceridemia. In the interim, both Dr. X and I have
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been considering together as to whether the patient should have an agent added to treat his
hypertriglyceridemia. Specifically we were considering TriCor (fenofibrate). Given his problems with high
CPK values in the past for now, we have decided not to engage in that strategy. We will leave open for
the future. Check fasting lipid panel today.
4. Chronic renal insufficiency, improved with reduction in dose of Bumex over time.
5. Arthritis, stable. I told the patient he could use Extra Strength Tylenol up to 4 grams a day, but I
suggest that he start with a regular dose of 1 to 2 to 3 grams per day. He states he will inch that up
slowly. With regard to a brace, he stated he used one in the past and that did not help very much. I
worry a little bit about the tourniquet type effect of a brace that could increase his edema or put him at
risk for venous thromboembolic disease. For now he will continue with his cane and walker.
6. Health maintenance, flu vaccination today.
Plans: Follow-up in 3 months, by phone sooner as needed.
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Sample Patient #3 - Acute Cystitis & Diabetes Type II
History Of Present Illness: The patient is a 45-year-old male complaining of abdominal pain.
Past Medical History: The patient also has a long-standing history of diabetes which is treated with
Micronase daily.
Family History: No significant family history.
Social History: No known history of drug or alcohol abuse. Work, diet, and exercise patterns are within
normal limits.
Physical Examination:
HEENT: Patient denies ear abnormalities, nose abnormalities and throat abnormalities.
Cardio: Patient has history of elevated cholesterol, but does not have ASHD, hypertension and PVD.
Resp: Patient denies asthma, lung infections and lung lesions.
GI: Patient denies colon abnormalities, gall bladder problems, liver abnormalities and peptic ulcer
disease.
GU: Patient has history of Urinary tract disorder, but does not have Bladder disorder and Kidney
disorder.
Endocrine: Patient has history of diabetes, but does not have hormonal irregularities and thyroid
abnormalities.
Dermatology: Patient denies allergic reactions, rashes and skin lesions.
Vital Signs: Height = 72 in. Weight =184 lbs. Upright BP = 120/80 mmHg. Pulse = 80 bpm. Resp =12 pm.
Patient is afebrile.
Neck: The neck is supple. There is no jugular venous distension. The thyroid is nontender, of normal size
and contour.
Lungs: Lung expansion and excursions are symmetric. The lungs are clear to auscultation and percussion.
Cardio: There is a regular rhythm. SI and S2 are normal. No abnormal heart sounds are detected. Blood
pressure is equal bilaterally.
Abdomen: Normal bowel sounds are present. The abdomen is soft; The abdomen is nontender; without
organomegaly; There is no CVA tenderness. No hernias are noted.
Extremities: There is no clubbing, cyanosis, or edema.
Assessment: Diabetes type II uncontrolled. Acute cystitis.
Plan: Endocrinology Consult, complete CBC.
Rx: Micronase 2.5 mg Tab PO QAM #30, Bactrim 400/80 Tab PO BID #30.
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Sample Patient #4 - Asthma in a 5-year-old (ED Visit)
Chief Complaint: This 5-year-old male presents to Children's Hospital Emergency Department by the
mother with "has asthma." Mother states he has been wheezing and coughing. They saw their primary
medical doctor. He was evaluated at the clinic, given the breathing treatment and discharged home, was
not having asthma, prescribed prednisone and an antibiotic. They told to go to the ER if he got worse.
He has had some vomiting and some abdominal pain. His peak flows on the morning are normal at 150,
but in the morning, they were down to 100 and subsequently decreased to 75 over the course of the
day.
Past Medical History: Asthma with his last admission in 07/2007. Also inclusive of frequent pneumonia
by report.
Immunizations: Up-to-date.
Allergies: Denied.
Medications: Advair, Nasonex, Xopenex, Zicam, Zithromax, prednisone, and albuterol.
Past Surgical History: Denied.
Social History: Lives at home, here in the ED with the mother and there is no smoking in the home.
Family History: No noted exposures.
Review Of Systems: Documented on the template. Systems reviewed on the template for this date, no
changes or additions.
Physical Examination:
VITAL SIGNS: Temperature 98.7, pulse 105, respiration is 28, blood pressure 112/65, and weight of 16.5
kg. Oxygen saturation low at 91% on room air.
GENERAL: This is a well-developed male who is cooperative, alert, active with oxygen by facemask.
HEENT: Head is atraumatic and normocephalic. Pupils are equal, round, and reactive to light. Extraocular
motions are intact and conjugate. Clear TMs, nose, and oropharynx.
NECK: Supple. Full painless, nontender range of motion.
CHEST: Tight wheezing and retractions heard bilaterally.
HEART: Regular without rubs or murmurs.
ABDOMEN: Soft, nontender. No masses. No hepatosplenomegaly.
GENITALIA: Male genitalia is present on a visual examination.
SKIN: No significant bruising, lesions or rash.
EXTREMITIES: Moves all extremities without difficulty, nontender. No deformity.
NEUROLOGIC: Symmetric face, cooperative, and age appropriate.
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Medical Decision Making: The differential entertained on this patient includes reactive airways disease,
viral syndrome, and foreign body pneumonia. He is evaluated in the emergency department with
continuous high-dose albuterol, Decadron by mouth, pulse oximetry, and close observation. Chest x-ray
reveals bronchial thickening, otherwise no definite infiltrate. She is further treated in the emergency
department with continued breathing treatments. At 0048 hours, he has continued tight wheezes with
saturations 99%, but ED sats are 92% with coughing spells. Based on the above, the hospitalist was
consulted and accepts this patient for admission to the hospital with the working diagnosis of
respiratory distress and asthma.
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Sample Patient #5 - Headache
The patient returns to our office today because of continued problems with her headaches. She was
started on Zonegran on her last visit and she states that initially she titrated up to 100 mg q.h.s. Initially
felt that the Zonegran helped, but then the pain in her head returned. It is an area of tenderness and
sensitivity in her left parietal area. It is a very localized pain. She takes Motrin 400 mg b.i.d., which
helped.
She also had EMG/nerve conduction studies since she was last seen in our office that showed severe left
ulnar neuropathy, moderate right ulnar neuropathy, bilateral mild-to-moderate carpal tunnel and
diabetic neuropathy. She was referred to Dr. XYZ and will be seeing him on August 8, 2006.
She was also never referred to the endocrine clinic to deal with her poor diabetes control. Her last
hemoglobin A1c was 10.
PMH: Diabetes, hypertension, elevated lipids, status post CVA, and diabetic retinopathy.
Medications: Glyburide, Avandia, metformin, lisinopril, Lipitor, aspirin, metoprolol and Zonegran.
Physical Examination: Blood pressure was 140/70, heart rate was 76, respiratory rate was 18, and
weight was 226 pounds. On general exam she has an area of tenderness on palpation in the left parietal
region of her scalp. Neurological exam is detailed on our H&P form. Her neurological exam is within
normal limits.
Impression and Plan: For her headaches we are going to titrate Zonegran up to 200 mg q.h.s. to try to
maximize the Zonegran therapy. If this is not effective, when she comes back on August 7, 2006 we will
then consider other anticonvulsants such as Neurontin or Lyrica. We also discussed the possibility of
nerve block injection; however, at this point she is not interested.
She will be seeing Dr. XYZ for her neuropathies.
We made an appointment in endocrine clinic today for counseling in terms of better diabetes control
and she is responsible for trying to get her referral from her primary care physician to go for this consult.
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Medicare
Part B
NOVITAS SOLUTIONS DOCUMENTATION WORKSHEET
Beneficiary HIC #
Provider Number
Date of Service
Procedure Code Reported
Check one:
q
Agree
q
Disagree
Documented Procedure Code Level
8985-4 (R3-12)
www.novitas-solutions.com
E/M Documentation Auditor’s Instructions
1. History
Refer to data section (table below) in order to quantify. After referring to data, circle the entry farthest to the RIGHT in the table, which
best describes the HPI, ROS and PFSH. If one column contains three circles, draw a line down that column to the bottom row to
identify the type of history. If no column contains three circles, the column containing a circle farthest to the LEFT, identifies the type
of history.
After completing this table which classifies the history, circle the type of history within the appropriate grid in Section 5.
HPI: Status of chronic conditions:
H I S T O R Y
q
1 condition
OR
q
2 conditions
q
3 conditions
HPI (history of present illness) elements:
q Location
q Severity
q Timing
q Quality
q Duration
ROS (review of systems):
q
q
Constitutional
(wt loss, etc)
Eyes
q
q
q
Ears,nose,
mouth, throat
Card/vasc
Resp
q
Context
q
q
q
GI
GU
Musculo
PFSH (past medical, family, social history) areas:
q
q
q
q
q
q
Modifying factors
q
Integumentary q
(skin, breast) q
Neuro
q
Psych
q
q
q
Status of 3
chronic
conditions
Brief
Extended
q
Associated signs and symptoms
q
(1-3)
q
Endo
Hem/lymph
All/immuno
All others negative
None
q
(4 or more)
q
q
*Complete
Pertinent to Extended
problem
(2-9 systems)
(1 system)
q
Past history ( the patient's past experiences with illnesses, operation, injuries and treatments)
Family history (a review of medical events in the patient's family, including diseases which may be
hereditary or place the patient at risk)
Social history (an age appropriate review of past and current activities)
*Complete ROS:
q
Status of
1-2 chronic
conditions
None
q
Pertinent
(1 history area)
q
**Complete
(2 or 3 history
areas)
PROBLEM EXP.PROB.
COMPREDETAILED
FOCUSED FOCUSED
HENSIVE
10 or more systems or the pertinent positives and/or negatives of
some systems with a statement “all others negative”.
**Complete PFSH: 2 history areas: a) Established Patients - Office (Outpatient) Care; b) Emergency Department.
3 history areas: a) New Patients - Office (Outpatient) Care, Domiciliary Care, Home Care; b) Initial Hospital Care;
c) Initial Hospital Observation; d) Initial Nursing Facility Care.
2. Examination
NOTE:For certain categories of E/M services that include only an interval history, it is not necessary to record
information about the PFSH. Please refer to procedure code descriptions.
Refer to data section (table below) in order to quantify. After referring to data, identify the type of examination.
Circle the type of examination within the appropriate grid in Section 5.
PROBLEM FOCUSED EXAM
Limited to affected body area or organ system (one body area or system related to problem)
EXPANDED PROBLEM
FOCUSED EXAM
Affected body area or organ system and other symptomatic or related organ system(s)
(additional systems up to total of 7)
Extended exam of affected area(s) and other symptomatic or related organ system(s)
(additional systems up to total of 7 or more depth than above)
DETAILED EXAM
EXAM
General multi-system exam (8 or more systems) or complete exam of a single organ system
(complete single exam not defined in these instructions)
Body areas:
q Head, including face
q Back, including spine
Organ systems:
q
q
q Chest, including breasts and axillae q
q Genitalia, groin, buttocks
q
Constitutional
q Ears,nose,
(e.g., vitals, gen app)
mouth, throat
Eyes
q Cardiovascular
q
q
q
Resp
GI
GU
q
q
q
Musculo
Skin
Neuro
Abdomen
q
Each extremity
q
q
Neck
Psych
Hem/lymph/imm
COMPREHENSIVE EXAM
q
1 body
area or
system
q
Up to 7
systems
q
Up to 7
systems
q
8 or more
systems
PROBLEM EXP.PROB.
DETAILED COMPREFOCUSED FOCUSED
HENSIVE
-1-
3. Medical Decision Making
Number of Diagnoses or Treatment Options
Amount and/or Complexity of Data Reviewed
Identify each problem or treatment option mentioned in the record.
Enter the number in each of the categories in Column B in the table
below. (There are maximum number in two categories.)
For each category of reviewed data identified, circle the number in the points
column. Total the points.
Amount and/or Complexity of Data Reviewed
Points
Reviewed Data
Number of Diagnoses or Treatment Options
A
B X C = D
Number Points Result
Problem(s) Status
Self-limited or minor
(stable, improved or worsening)
D E C I S I O N
M A K I N G
Est. problem (to examiner); stable, improved
Max = 2
Est. problem (to examiner); worsening
New problem (to examiner); no additional
workup planned
New prob. (to examiner); add. workup planned
M E D I C A L
Review and summarization of old records and/or obtaining
history from someone other than patient and/or discussion of
case with another health care provider
4
Independent visualization of image, tracing or specimen itself
(not simply review of report)
TOTAL
Multiply the number in columns B & C and put the product in column D.
Enter a total for column D.
Minimal
Low
•
•
•
•
•
Moderate
•
•
•
•
One self-limited or minor problem,
e.g., cold, insect bite, tinea corporis
Two or more self-limited or minor problems
One stable chronic illness, e.g., well controlled
hypertension or non-insulin dependent diabetes,
cataract, BPH
TOTAL
•
•
•
•
•
•
•
•
•
•
•
•
•
•
• One or more chronic illnesses with severe exacerbation,
High
progression, or side effects of treatment
• Acute or chronic illnesses or injuries that may pose a threat to
•
life or bodily function, e.g., multiple trauma, acute MI,
pulmonary embolus, severe respiratory distress, progressive
severe rheumatoid arthritis, psychiatric illness with potential
threat to self or others, peritonitis, acute renal failure
An abrupt change in neurologic status, e.g., seizure, TIA,
weakness or sensory loss
•
•
•
•
Laboratory tests requiring venipuncture
Chest x-rays
EKG/EEG
Urinalysis
Ultrasound, e.g., echo
KOH prep
Physiologic tests not under stress, e.g.,pulmonary
function tests
Non-cardiovascular imaging studies with contrast,
e.g., barium enema
Superficial needle biopsies
Clincal laboratory tests requiring arterial puncture
Skin biopsies
Physiologic tests under stress, e.g., cardiac stress test,
fetal contraction stress test
Diagnostic endoscopies with no identified risk factors
Deep needle or incisional biopsy
Cardiovascular imaging studies with contrast and no
identified risk factors, e.g., arteriogram cardiac cath
Obtain fluid from body cavity, e.g., lumbar puncture,
thoracentesis, culdocentesis
Cardiovascular imaging studies with contrast with
identified risk factors
Cardiac electrophysiological tests
Diagnostic endoscopies with identified risk factors
Discography
Draw a line down any column with 2 or 3 circles to identify the type of decision making in
that column. Otherwise, draw a line down the column with the 2nd circle from the left.
After completing this table, which classifies complexity, circle the type of decision
making within the appropriate grid in Section 5.
B
C
treatment options
Highest Risk
Amount and complexity
of data
Type of decision making
Minimal
1
Minimal
or low
≤
2
Limited
3
Multiple
4
Extensive
Low
Moderate
High
2
Limited
3
Multiple
2
2
•
•
•
•
Rest
Gargles
Elastic bandages
Superficial dressings
•
•
•
•
•
Over-the-counter drugs
Minor surgery with no identified risk factors
Physical therapy
Occupational therapy
IV fluids without additives
•
•
•
•
•
•
•
•
•
•
•
Minor surgery with identified risk factors
Elective major surgery (open, percutaneous or
endoscopic) with no identified risk factors
Prescription drug management
Therapeutic nuclear medicine
IV fluids with addititives
Closed treatment of fracture or dislocation without
manipulation
Elective major surgery (open, percutaneous or
endoscopic with identified risk factors)
Emergency major surgery (open, percutaneous or
endoscopic)
Parenteral controlled substances
Drug therapy requiring intensive monitoring for toxicity
Decision not to resuscitate or to de-escalate care
because of poor prognosis
4. Time
If the physician documents total time and suggests that counseling or coordinating care dominates
(more than 50%) the encounter, time may determine level of service. Documentation may refer to:
prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk
reduction or discussion with another health care provider.
≥
≥ 4
Extensive
LOW
MODERATE
HIGH
STRAIGHTFORWARD COMPLEX. COMPLEX. COMPLEX.
1
Management Options
Selected
Diagnostic Procedure(s)
Ordered
Final Result for Complexity
Final Result for Complexity
≤ 1
A Number diagnoses or
Minimal
1
Use the risk table below as a guide to assign risk factors. It is understood that the table below does not
contain all specific instances of medical care; the table is intended to be used as a guide. Circle the
most appropriate factor(s) in each category. The overall measure of risk is the highest level circled.
Enter the level of risk identified in Final Result for Complexity (table below).
•
One or more chronic illnesses with mild exacerbation,
progression, or side effects of treatment
Two or more stable chronic illnesses
Undiagnosed new problem with uncertain prognosis,
e.g., lump in breast
Acute illness with systemic symptoms, e.g.,
pyelonephritis, pneumonitis, colitis
Acute complicated injury, e.g., head injury with brief loss
of consciousness
1
Bring total to line C in Final Result for Complexity (table below)
•
Acute uncomplicated illness or injury, e.g., cystitis, allergic
rhinitis, simple sprain
1
Decision to obtain old records and/or obtain history from
someone other than patient
3
Risk of Complications and/or Morbidity or Mortality
Level of
Presenting Problem(s)
Risk
Review and/or order of tests in the medicine section of CPT
Discussion of test results with performing physician
1
1
Bring total to line A in Final Result for Complexity (table below)
1
Review and/or order of tests in the radiology section of CPT
2
Max = 1
Review and/or order of clinical lab tests
Face-to-face in outpatient setting
Does documentation reveal total time? Time: Unit/floor in inpatient setting
Yes
No
Does documentation reveal that more than half of the time was counseling or
coordinating care?
Yes
No
Does documentation describe the content of counseling or coordinating care?
-2-
If all answers are "yes", select level based on time.
Yes
No
5.
L E V E L
OF
S E R V I C E
New Office, Outpatient and Emergency Room
PF
ER: PF
PF
History
Examination
Complexity
of medical
decision
Average time
(minutes)
New Office / Outpatient / ER
Requires 3 components within shaded area
EPF
ER: EPF
EPF
ER: PF
SF
ER: SF
ER: EPF
SF
ER: L
10 New (99201)
ER has no average
time
Level
D
ER: EPF
D
ER: EPF
L
ER: M
20 New (99202)
ER (99281)
I
45 New (99204)
60 New (99205)
ER (99283)
II
Hospital Care
C
ER: C
C
ER: C
H
ER: H
ER: D
M
ER: M
30 New (99203)
ER (99282)
C
ER: D
C
ER (99284)
III
IV
Examination
C
D/C
Complexity of medical
decision
Average time (minutes)
Level
Nursing Facility
Care
SF/L
M
I
D/C
Examination
C
D/C
Complexity of medical
decision
Average time (minutes)
Level
C
C
SF/L
25
99304
C
M
35
99305
I
SF
L
M
H
PF
EPF
II
C
25
(99213)
40
(99214)
III
(99215)
IV
EPF interval
V
I
PF interval EPF interval D interval
PF
EPF
SF
10
99307
D
L
15
99308
I
M
25
99309
II
III
D interval
EPF
D
M
H
25 Sub hosp (99232)
25 Sub observ care
(99225)
35 Sub hosp (99233)
35 Sub observ care
(99226)
II
III
Other Nursing Facility
(Annual Assessment)
Requires 2 components within shaded area
III
D
15
10
(99212)
Subsequent Nursing Facility
H
45
99306
II
SF/L
15 Sub hosp (99231)
15 Sub observ care
(99224)
III
Requires 3 components within shaded area
History
C
PF
H
Initial Nursing Facility
D
PF interval
70 Init hosp (99223)
70 Init observ Care
(99220)
II
I
EPF
Requires 2 components within shaded area
C
50 Init hosp (99222)
50 Init observ Care
(99219)
5
(99211)
PF
Subsequent Hospital/Observation
C
C
30 Init hosp (99221)
30 Init observ Care
(99218)
Minimal
problem
that may
not
require
presence
of
physician
V
Initial Hospital/Observation
D/C
Requires 2 components within shaded area
ER (99285)
Requires 3 components within shaded area
History
Established Office / Outpatient
Requires 3 components within shaded area
C interval
D interval
C
C
H
35
99310
L/M
30
99318
IV
Domiciliary, Rest Home (eg, Boarding Home), or Custodial Care Services and Home Care
Establishe
New
History
Examination
Complexity of
medical decision
Average time
(minutes)
Level
PF = Problem focused
PF
PF
SF
Requires 3 components within shaded area
EPF
D
C
C
L
M
M
H
EPF
D
C
C
Requires 2 components
within shaded area
d
PF interval EPF interval
PF
EPF
L
SF
D interval
D
C interval
C
M
M/H
III
IV
60
75
40
25
60
15
20
30
45
Domiciliary (99324) Domiciliary (99325) Domiciliary (99326) Domiciliary (99327) Domiciliary (99328) Domiciliary (99334) Domiciliary (99335) Domiciliary (99336) Domiciliary (99337)
Home care (99341) Home care (99342) Home care (99343) Home care (99344) Home care (99345) Home care (99347) Home care (99348) Home care (99349) Home care (99350)
I
II
EPF = Expanded problem focused
III
D = Detailed
IV
C = Comprehensive
-3-
V
I
SF = Straightforward
L = Low
II
M = Moderate
H = High
SPECIALTY EXAM: GENERAL MULTI-SYSTEM
HIC#
DATE OF SERVICE
Refer to data section (table below) in order to quantify. After reviewing the medical record documentation, identify the
level of examination. Circle the level of examination within the appropriate grid in Section 5 (Page 3).
Performed and Documented
Level of Exam
One to five bullets
Problem Focused
At least six bullets
Expanded Problem Focused
At least two bullets from each of six body systems/areas
OR at least twelve bullets in any two or more body
systems/areas.
Detailed
At least two bullets from each of nine body systems/areas
Comprehensive
System/Body
Area
Neck
Respiratory
(Circle the bullets that are documented.)
NOTE: For the descriptions of the elements of examination containing the words "and", "and/or", only one (1) of those
elements must be documented.
System/Body
Area
Constitutional
Eyes
Ears, Nose, Mouth and
Throat
10229-1 11/97
Elements of Examination
z
Examination of neck (e.g., masses, overall appearance, symmetry, tracheal position,
crepitus)
z
Examination of thyroid (e.g., enlargement, tenderness, mass)
z
Assessment of respiratory effort (e.g., intercostal retractions, use of accessory
muscles, diaphragmatic movement)
z
Percussion of chest (e.g., dullness, flatness, hyperresonance)
z
Palpation of chest (e.g., tactile fremitus)
z
Auscultation of lungs (e.g., breath sounds, adventitious sounds, rubs)
z
Palpation of heart (e.g., location, size, thrills)
z
Auscultation of heart with notation of abnormal sounds and murmurs
Elements of Examination
Cardiovascular
z
Measurement of any three of the following seven vital signs: 1) sitting or
standing blood pressure, 2) supine blood pressure, 3) pulse rate and
regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be
measured and recorded by ancillary staff)
z
General appearance of patient (e.g., development, nutrition, body habitus,
deformities, attention to grooming)
z
Inspection of conjunctivae and lids
z
Examination of pupils and irises (e.g., reaction to light and accommodation,
size and symmetry)
z
Ophthalmoscopic examination of optic discs (e.g., size, C/D ratio,
appearance) and posterior segments (e.g., vessel changes, exudates,
hemorrhages)
Examination of:
Chest (Breasts)
z
Carotid arteries (e.g., pulse amplitude, bruits)
z
Abdominal aorta (e.g., size, bruits)
z
Femoral arteries (e.g., pulse amplitude, bruits)
z
Pedal pulses (e.g., pulse amplitude)
z
Extremities for edema and/or varicosities
z
Inspection of breasts (e.g., symmetry, nipple discharge)
z
Palpation of breasts and axillae (e.g., masses or lumps, tenderness)
z
Examination of abdomen with notation of presence of masses or tenderness
z
External inspection of ears and nose (e.g., overall appearance, scars, lesions,
masses)
z
Otoscopic examination of external auditory canals and tympanic membranes
z
Examination of liver and spleen
z
Assessment of hearing (e.g., whispered voice, finger rub, tuning fork)
z
Examination for presence or absence of hernia
z
Inspection of lips, teeth and gums
z
Examination of anus, perineum and rectum, including sphincter tone, presence of
hemorrhoids, rectal masses
z
Examination of oropharynx: oral mucosa, salivary glands, hard and soft
palates, tongue, tonsils and posterior pharynx
z
Obtain stool sample for occult blood test when indicated
z
Inspection of nasal mucosa, septum and turbinates
1a
Gastrointestinal
(Abdomen)
1b
HIC#
DATE OF SERVICE
SPECIALTY EXAM: GENERAL MULTI-SYSTEM (CONT.)
System/Body
Area
NOTE: Determine the
number of body areas
addressed within each bullet.
Enter that number on the
corresponding line below.
Total at the bottom of this box.
Inspection and/or palpation:
Assessment of range of
motion:
Assessment of stability:
Assessment of muscle
strength:
z
Examination of gait and station
*(if circled, add to total at bottom of column to the left)
z
Inspection and/or palpation of digits and nails (e.g., clubbing, cyanosis,
inflammatory conditions, petechiae, ischemia, infections, nodes)
*(if circled, add to total at bottom of column to the left)
Neurologic
Psychiatric
z
Inspection and/or palpation with notation of presence of any misalignment,
asymmetry, crepitation, defects, tenderness, masses, effusions
z
Assessment of range of motion with notation of any pain, crepitation or
contracture
z
Assessment of stability with notation of any dislocation (luxation),
subluxation or laxity
z
Assessment of muscle strength and tone (e.g., flaccid, cog wheel, spastic)
with notation of any atrophy or abnormal movements
z
Inspection of skin and subcutaneous tissue (e.g., rashes, lesions, ulcers)
z
Palpation of skin and subcutaneous tissue (e.g., induration, subcutaneous
nodules, tightening)
z
Test cranial nerves with notation of any deficits
z
Examination of deep tendon reflexes with notation of pathological reflexes
(e.g., Babinski)
z
Examination of sensation (e.g., by touch, pin, vibration, proprioception)
z
Description of patient's judgement and insight
z
Orientation to time, place and person
z
Recent and remote memory
z
Mood and affect (e.g., depression, anxiety, agitation)
1c
Elements of Examination
MALE:
z
Examination of the scrotal contents (e.g., hydrocele, spermatocele, tenderness of cord,
testicular mass)
z
Examination of penis
z
Digital rectal examination of prostrate gland (e.g., size, symmetry, nodularity,
tenderness)
FEMALE:
Pelvic examination (with or without specimen collection for smears and cultures), including:
Lymphatic
Brief assessment of mental status including:
10229-2 11/97
Genitourinary
Examination of joints, bones and muscles of one or more of the following six
areas: 1) head and neck; 2) spine, ribs, and pelvis; 3) right upper extremity;
4) left upper extremity; 5) right lower extremity; and 6) left lower extremity. The
examination of a given area includes:
* Total Bullets:
(including gait and station
and inspection and/or
palpation of digits and nails if
circled)
Skin
System/Body
Area
z
Examination of external genitalia (e.g., general appearance, hair distribution, lesions)
and vagina (e.g., general appearance, estrogen effect, discharge, lesions, pelvic
support, cystocele, rectocele)
z
Examination of urethra (e.g., masses, tenderness, scarring)
z
Examination of bladder (e.g., fullness, masses, tenderness)
z
Cervix (e.g., general appearance, lesions, discharge)
z
Uterus (e.g., size, contour, position, mobility, tenderness, consistency, descent or
support)
z
Adnexa/parametria (e.g., masses, tenderness, organomegaly, nodularity)
Palpation of lymph nodes in two or more areas:
z
Neck
z
Axillae
z
Groin
z
Other
(Enter the number of circled bullets in the boxes below. Then circle the appropriate level of care.)
This level requires that one of the following
questions be answered with a "yes."
EXAM
Musculoskeletal
Elements of Examination
One to Five
Bullets
Six to Eleven
Bullets
Problem Focused
Expanded Problem
Focused
Have you circled at least two bullets in each
of six body systems/areas?
ˆ Yes
ˆ No
Are there a total of twelve bullets circled in
two or more body systems/areas?
ˆ Yes
ˆ No
Detailed
1d
At least two bullets from
each of nine body
systems/areas
Comprehensive