E/M Calculator
Patient Account Number: Patient MRN: DOS:
Insurance: Diagnosis: Initial E/M Code:
Type of Service:
Type of Visit:
Chief Complaint:

 1. History

A. History of Present Illness (HPI):
B. Review of Systems (ROS):




C. Past, Family, Social History (PFSH):
   

 2. Physical Examination

 3. Medical Decision Making
Table of Risk
Is Medical Decision Making required as one of the two key components when determining the level of service?   
A. Number of Diagnoses / Management Options
PROBLEM CATEGORIES NUMBER POINTS SCORE
Self-Limiting or minor; stable/improving (Max2) 1
Established problem; stable/improved 1
Established problem; worsening 2
New problem; no additional work up planned (Max1) 3
New problem; additional work up planned 4
    Total :   0
B. Amount and/or Complexity of Data to be Reviewed (Total: 0)






C. Level of Risk:

Comment for Level of Risk

  4. Visit / Consultation / Examination Time    

Does documentation indicate over 50% of the visit was spent in counseling and coordination of care?  
Does documentation indicate the content of counseling and coordination of care?   
What was the total time of the examination/visit?   (minutes)


  
  History of Present Illness (HPI)  
 
   

RISK LEVEL

PRESENTING PROBLEMS

DIAGNOSTIC PROCEDURES

MANAGEMENT OPTIONS SELECTED

Minimal
  • One self-limited or minor problem (e.g., cold, insect bite, tinea corporis)
  • Laboratory tests requiring venepuncture
  • Chest X-rays
  • EKG/EEG
  • Urinalysis
  • Ultrasound (e.g. Echocardiography)
  • KOH prep
  • Rest
  • Gargles
  • Elastic bandages
  • Superficial dressings

Low
  • Two or more self-limited or minor problems
  • One stable chronic illness (e.g., well controlled hyper tension, non-insulin dependent diabetes, cataract, BPH)
  • Acute uncomplicated injury or illness (e.g., cystitis, allergic rhinitis, simple sprain)
  • Physiologic tests not under stress (e.g., Pulmonary function tests)
  • Non-cardiovascular imaging studies with contrast (e.g., barium enema)
  • Superficial needle biopsy
  • Clinical laboratory tests requiring atrial puncture
  • Skin biopsies
  • Over the counter drugs
  • Minor surgery, with no identified risk factors
  • Physical therapy
  • Occupational therapy
  • IV fluids without additives

Moderate
  • One or more chronic illness with mild exacerbation or 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 systematic symptoms (e.g., pyelonephritis pneumonitis, colitis)
  • Acute complicated injury, e.g., head injury, with brief loss of consciousness
  • Physiologic tests under stress (e.g., cardiac stress test, fetal contraction stress test)
  • Diagnostic endoscopies, with no identified risk factors
  • Deep needle, or incisional biopsies
  • Cardiovascular imaging studies, with contrast, with no identified risk factors (e.g., arteriogram, cardiac catheterization)
  • Obtain fluid from body cavity (e.g., lumbar puncture, thoracentesis, cudocentesis)
  • 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

High
  • One or more chronic illness, with severe exacerbation, progression or side effects of treatment
  • Acute or chronic illness or injury, which poses a threat to life or bodily function (e.g., multiple trauma, acute MI, pulmonary embolism, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness, with potential threat to self or others, peritonitis, acute renal failure)
  • An abrupt change in neurological status (e.g., seizure, TIA, weakness, sensory loss)
  • Cardiovascular imaging, with contrast, with identified risk factors
  • Cardiac electrophysiological tests
  • Diagnostic endoscopies, with identified risk factors
  • Discography
  • Elective major surgery (open, percutaneous, endoscopic), with identified risk factors
  • Emergency major surgery (open, percutaneous, endoscopic)
  • Parenteral controlled substances
  • Drug therapy requiring intensive monitoring for toxicity
  • Decision not to resuscitate, or to de-escalate care because of poor prognosis
Code History Exam MDM NOPP
99281 Problem-focused Problem-focused Straight Forward Self-Limited or Minor
99282 Expanded Problem Focused Expanded Problem Focused Low Low to Moderate
99283 Expanded Problem Focused Expanded Problem Focused Moderate Complexity Moderate
99284 Detailed Detailed Moderate Complexity High, requires urgent evaluation w/o immediate significant threat to life or physiological function
99285 Comprehensive Comprehensive High Complex High, poses an immediate significant threat to life or physiological function
  Past, Family, Social History (PFSH)
 
     
  Review of Systems (ROS)
 
     
  1995 Guidelines
 
     
  General Multiple System
 
     
  Single Organ System
 
     
  Medical Decision Making
 
     
  Chief Complaint
 
     
As Per 1995 Guidelines
Select
As Per 1997 Guidelines
Select
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