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1997 Evaluation and Management Services Coding Tool (General Multi-System) Rev. 4/11/08
 Chief Complaint
 New Patient
 Est Patient
 Consultation
HISTORY
HPI (History of Present Illness)
 Location
 Duration
 Mod. Factors  Quality
 Severity
 Timing
 Context
 Associated signs & symptoms
OR Status of chronic/inactive conditions 1  2  3 
ROS (Review of Systems)
 Constitutional
 Eyes
 ENMT
 Card/vasc
 Neuro
 GI
 Musculo
 Resp
 GU
 Hem/Lymph  Psych
 All/imm
Integ
Endo
PFSH (Past medical, Family and Social History)
 Past (patient’s illnesses, operation, injuries & treatments)
 Family (review of medical events in pt’s family incl. hereditary disease placing pt at risk)
 Social (age appropriate review of past & current activities)
* Complete PFSH:
2 Hx areas: a) Established pts. - office visit; domiciliary care; home care; b) Emergency dept. visit; and, c)
Subsequent nursing facility care.
3 Hx areas: a) New patients. - office visit; domiciliary care; home care; b) Consultations; c) Initial hospital
care; d) hospital observation; and, e) Comprehensive nursing facility assessments.

Brief
(1-3 elements, or status of 1-2
chronic conditions)

Pertinent to
problem
(1 system)

None

None
ProblemFocused
(PF)
Expanded Problem
Focused (EPF)

Extended
(4 or more elements, or status of 3 chronic or inactive
conditions)

Extended
(2-9 systems including 1
pertinent)

Complete
(10 or more systems
including 1 pertinent)

Complete
New or Consult :
3 history areas
Established:
2 history areas

Pertinent
(1 history area)
Comprehensive ( C )
Detailed (D)
Final level of history requires 3 components above met or exceeded
EXAMINATION
Constitutional:
 Vital Signs: Any 3 of the following: 1) Sitting BP or standing BP, 2) supine BP, 3) pulse rate / regularity, 4)
respiration, 5) temperature, 6) height, 7) weight
 General Appearance: (eg Development, nutrition, body habitus, deformities, attention to grooming, etc.)
Eyes:  Inspection of conjunctivae and lids  Examine pupils and irises (eg reaction to light & accommodation,
size, and symmetry)  Ophthalmoscopic exam of optic discs (size, C/D ratio, appearance) and posterior
segments (eg vessel changes, exudates, hemorrhages)
ENMT:  External inspection ears and nose (eg overall appearance, scars, lesions, masses)
 Otoscopic exam – ext. auditory canals & TMs’;  Assess hearing (eg whispered voice, finger rub, tuning
fork)  Inspect nasal mucosa, septum, turbinates;  Inspect teeth, gums;
 Inspection of oropharynx (eg oral mucosa, salivary glands, hard & soft palates, tongue, tonsils, posterior
pharynx)
Neck:  Examine neck (eg masses, symmetry, tracheal position, crepitus, overall appearance)
 Examination of thyroid (eg, enlargement, tenderness, mass)
Respiratory:  Assessment of respiratory effort (eg intercostal retractions, use of accessory muscles,
diaphragmatic movement)  Chest percussion (eg dullness, flatness, hyperresonance)  Chest palpation
(tactile fremitus)  Auscultation of lungs (eg breath sounds, adventitious sounds, rubs)
Cardiovascular:  Palpation of heart (eg, location, size, thrills)
 Auscultation of heart including sounds, abnormal sounds and murmurs
Examination of
 Carotid arteries (eg, waveform, pulse amplitude, bruits, apical-carotid delay)
 Abdominal aorta (eg, size, bruits)
 Femoral arteries (eg, pulse amplitude, bruits)
 Pedal pulses (eg, pulse amplitude)
 Extremities for edema and/or varicosities



Chest (Breasts)
 Inspection (eg symmetry, nipple discharge)
1-5
6-11
elements
Includes
at
least 6 organ
 Palpation of breasts & axillae (eg masses, lumps, tenderness)
elements
systems or body areas;
GI/Abdomen  Examination of abdomen with notation of presence of masses or tenderness
for each system/area
 Examination of liver and spleen  Examination presence/absence hernia
selected, document at
 Exam (when indicated) anus, perineum, rectum (including sphincter tone, +/- hemorrhoids &/or masses)
least
2 elements identified
 Stool sample for occult blood test (when indicated)
by a bullet ()
GU- Male:  Scrotum (hydrocele, spermatocele, cord tenderness, testicular mass)  Penis  Digital rectal
exam of prostate (size, symmetry, nodularity, tenderness)
OR
GU- Female: Pelvic exam (with or w/o specimen collection for smear/cultures):  External genitalia and vagina
12 or more elements
(eg general appearance, hair distribution, lesions, estrogen effect, discharge, pelvic support, cystocele,
identified by a bullet ()
rectocele)  Urethra (eg masses, tenderness, scarring)  Bladder (eg fullness, masses, tenderness) 
in 2 or more organ
Cervix (eg general appearance, lesions, discharge)  Uterus (eg size, contour, position, mobility, tenderness,
systems/body areas
consistency, descent or support)  Adnexa/parametria (eg masses, tenderness, organomegaly, nodularity)
Lymphatic
 Palpation of lymph nodes in 2 or more areas: neck, axillae, groin, and/or other location
Skin
 Inspection and  palpation of skin and subcutaneous tissue (eg, rashes, lesions, scars, induration,
subcutaneous nodules, tightening)
Musculoskeletal:

Gait & Station

Digits & Nails: Inspection and palpation (eg, clubbing, cyanosis, inflammation, petechiae, ischemia,
infections, nodes)

Joint/Bone/Muscle exam of 1 or more of the following 6 areas: 1) Head & neck; 2) Spine, ribs, &
pelvis; 3) Rt. Upper extremity; 4) Lt. upper extremity; 5) Rt. Lower extremity; 6) Lt. lower extremity. Exam
of a given area includes:
o
Inspect/palpate, noting any misalignment, asymmetry, crepitus, defects, tenderness,
masses, effusions
o
Assess ROM, noting any pain, crepitus, or contracture
o
Assess stability, noting any dislocation, subluxation, or laxity
o
Assess muscle strength/tone, noting any atrophy or abnormal movements
Neurological:  Test cranial nerves, noting any deficits  Examine DTR’s, noting any pathological reflexes 
Problem
Expanded
Detailed
Focused
Problem Focused
(D)
Examine sensation (eg touch, pin, vibration, propioception)
(PF)
(EPF)
Psychiatric:  Description of patient’s judgment and insight
Brief assessment of mental status including  Orientation to time, place and person  Recent & remote
memory  Mood and affect (eg, depression, anxiety, agitation)
MEDICAL DECISION MAKING
A.1 Number of Diagnoses and/or Management Options
NOTE: A “problem” is defined as a definitive diagnosis, or, for undiagnosed problems, a related group of presenting symptoms and/or clinical findings

Includes at least 9 organ
systems or body areas; for
each system/area selected,
document at least 2 elements
identified by a bullet ()
EACH new or established problem for which the diagnosis and/or treatment plan is evident with or without diagnostic confirmation
Per Problem
1 point
EACH new or established problem for which the diagnosis and/or treatment plan is not evident; 2 plausible differential diagnoses, comorbidities, or
complications (not counted as separate problems) clearly stated and supported by information in record; requiring diagnostic evaluation or confirmation
EACH new or established problem for which the diagnosis and/or treatment plan is not evident; 3 plausible differential diagnoses, comorbidities, or
complications (not counted as separate problems) clearly stated and supported by information in record; requiring diagnostic evaluation or confirmation
Per Problem
2 points
Per Problem
3 points
EACH new or established problem for which the diagnosis and/or treatment plan is not evident; 4 plausible differential diagnoses, comorbidities, or
complications (not counted as separate problems) clearly stated and supported by information in record; requiring diagnostic evaluation or confirmation
Per Problem
4 points
Total Diagnoses (Box A1) (If total is greater than total points for Box A2, use in Box D)
.
Comprehensive
(C)
# Dxs
1997 Evaluation and Management Services Coding Tool (General Multi-System) Rev. 4/11/08
A.2 Treatments and Therapeutic Options
Pts
Continue “same” therapy or “no change” in therapy (including drug management) if specified therapy
is not described in documentation and documented that the physician reviewed therapy)
Drug management, per problem. Includes “same” therapy or
“no change” in therapy if specified therapy is described
(document current therapy + that provider reviewed it). Record
must reflect conscious decision-making to make no-dose
changes in order to count for coding purposes.
≤ 3 new or current
meds per problem
> 3 new or current
meds per problem
0
1 pt Per
Problem
2 pts
Per
Problem
BOX B. Amount and/or Complexity of Data Reviewed or Ordered
Order and/or review of medically reasonable and
necessary clinical lab tests ( 1 lab panel = 1 procedure)
Order and/or review results of medically reasonable
and necessary tests in Radiology section of CPT
Order and/or review results of medically reasonable
and necessary tests in Medicine section of CPT
Pts
1-3 procedures: 1 pt
≥ 4 procedures: 2 pts
1-3 procedures: 1 pt
≥ 4 procedures: 2 pts
1-3 procedures: 1 point
≥ 4 procedures: 2 points
Discuss case with other physician managing patient’s care or request consult from other
physician (referral does not count)
Major or Minor surgical procedure(s)
1
Closed treatment for fracture/dislocation
1
Physical therapy, occupational therapy, speech therapy, or other manipulation
1
Complex insulin Rx (SC or combo), hyperalimentation, insulin drip, or other complex IV admix Rx
IV fluid/fluid component replacement, establish IV access when record is clear that such involved
physician decision-making and wasn’t standard facility “protocol”
2
1
Pain management procedure
Joint, body cavity, soft tissue, etc. injection/aspiration
1
1
Conservative measures such as rest, ice bandages, dietary
Patient educated on self or home care topics/techniques
1
1
Decision to admit to hospital
1
Discuss case with other physician
1
Other-specify
1
Discuss test results with performing physician
Order or review old records. Record type/source must be
documented. Review must be reasonable + necessary based
on patient’s condition. Practice/facility protocol driven review, or
review only for coding is not permitted.
1
Without summary:
1 point
With summary:
2 points
Review of significant physiologic monitoring or testing data not reported for separate
payment
Independently visualization and interpretation of an image,
EKG, or lab specimen not reported for separate payment
1
Each visualization and
interpretation
= 1 point
1
1
1
TOTAL for Box B (Bring results to BOX D)
Total Management Options (Box A2) (If total is > total points for Box A1, use in Box D)
C. Risk of Complications and/or Morbidity or Mortality
C.1 Levels of Risk
Level of Risk
Nature of Presenting Illness/Problem(s)
Minimal
Low




Moderate
High
One self-limited or minor problems; 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
Acute uncomplicated illness or injury; e.g., cystitis, allergic
rhinitis, simple sprain
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 illness with severe exacerbation,
Diagnostic Procedure Ordered





Laboratory tests requiring venipuncture
Chest x-rays
EKG/EEG
Urinalysis
Ultrasound, e.g., echocardiography
Physiological 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 w/contrast and no
identified risk factors, e.g., arteriogram, cardiac
catheterization
 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
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., seizures, TIA,
weakness, or sensory loss
Final risk is determined by the highest of the 3 components above – take highest level to Box D
Management Options Selected




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 w/ identified risk factors
 Elective major surgery (open, percutaneous, or endoscopic) w/
no identified risk factors
 Prescription drug management
 Therapeutic nuclear medicine
 IV fluids with additives
 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
 Decisions not to resuscitate or to de-escalate care because of
poor prognosis
BOX D. Final Result for Complexity of Medical Decision-Making (MDM)
Box A
Box B
Box C
Number of diagnoses and/or management options
1 point – Minimal
2 points - Limited
3 points – Multiple
Amount and complexity of data reviewed or ordered
2 points - Limited
3 points – Multiple
 1 point - None/Minimal
Risk of complications and/or morbidity or mortality
Minimal
Low
Moderate
Type of Medical decision-making
Straightforward
Low Complexity
Moderate Complexity
Final MDM requires that 2 of 3 of the above components are met or exceeded
≥ 4 points - Extensive
≥ 4 points - Extensive
High
High Complexity
Evaluation and Management (E/M) Level of Service
New Pt Outpatient Visit
Requires 3 of 3 components met
Consult Outpatient Visit
Requires 3 of 3 components met
E/M Code
History
Exam
MDM
Average Time
E/M Code
History
Exam
MDM
Average Time
99201
PF
PF
S
10
99241
PF
PF
S
15
99202
EPF
EPF
S
20
99242
EPF
EPF
S
30
99203
D
D
L
30
99243
D
D
L
40
99204
C
C
M
45
99244
C
C
M
60
99205
C
C
H
60
99245
C
C
H
80
Established Pt Outpatient Visit : Requires 2 of 3 components met; 1 must be MDM
ER Visit
Requires 3 of 3 components met
99211
NA
NA
NA
5
99281
PF
PF
S
NA
99212
PF
PF
S
10
99282
EPF
EPF
L
NA
99213
EPF
EPF
L
15
99283
EPF
EPF
M
NA
99214
D
D
M
25
99284
D
D
M
NA
99215
C
C
H
40
99285
C
C
H
NA
TIME
If the attending physician documented that the visit was dominated (more than 50%) by counseling or coordinating care, time may be used to determine the level of service. In addition to any history, examination or
MDM documented, documentation must include the total visit time, counseling/coordination of care time, and details of the counseling/coordination of care. Details may include prognosis, differential diagnosis, risks,
benefits of treatment, instructions, compliance, etc. If all the answers to the below 3 questions are “yes”, the total visit time may be used to select the level of the service.
Does the attending physician’s documentation indicate the total face-to-face visit time?
□ Yes
□ No
1997 Evaluation and Management Services Coding Tool (General Multi-System) Rev. 4/11/08
Does the attending physician’s documentation indicate that more than 50% of the time was counseling or coordinating the patient’s care?
Does documentation describe the content of counseling or coordinating the patient’s care?
□ Yes
□ Yes
□ No
□ No