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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