Patient Account Number
Patient MRN
DOS *
 
Insurance
Diagnosis
Initial E/M Code
   
POS
Modifiers
Telehealth Service:  
Type of Service *
Type of Visit *
   
Mode of Arrival:
     
Chief Complaint:
Not Originating from E/M in previous 7 days?
Not Leading to an appointment in next 24 hours?

 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
Is Medical Decision Making required as one of the two key components when determining the level of service?   
Auditor recommended MDM:
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:
Table of Risk

Comment for Level of Risk

Disposition:

  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 Venipuncture
  • 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, culdocentesis)
  • 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

Level of MDM (Based on 2 out of 3 Elements of MDM)

Elements of Medical Decision Making

Number and Complexity of Problems Addressed

Amount and/or Complexity of Data to be Reviewed and Analyzed
Each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1 below.

Risk of Complications and/or Morbidity or Mortality of Patient Management
99211 N/A N/A N/A N/A
99202
99212		 Straightforward Minimal
  • 1 self-limited or minor problem
Minimal or none Minimal risk of morbidity from additional diagnostic testing or treatment
99203
99213		 Low Low
  • 2 or more self-limited or minor problems
    or
  • 1 stable chronic illness;
    or
  • 1 acute, uncomplicated illness or injury
Limited
(Must meet the requirements of at least 1 of the 2 categories)
Category 1: Tests and documents
  • Any combination of 2 from the following:
    • Review of prior external note(s) from each unique source*;
    • review of the result(s) of each unique test*;
    • ordering of each unique test*
or
Category 2: Assessment requiring an independent historian(s) 		Low risk of morbidity from additional diagnostic testing or treatment
99204
 Moderate Moderate
  • 1 or more chronic illnesses with exacerbation progression, or side effects of treatment;
    or
  • 2 or more stable chronic illnesses;
    or
  • 1 undiagnosed new problem with uncertain prognosis;
    or
  • 1 acute illness with systemic symptoms;
    or
  • 1 acute complicated injury
Moderate
(Must meet the requirements of at least 1 out of 3 categories)
Category 1: Tests, documents, or independent historian(s)
  • Any combination of 3 from the following:
    • Review of prior external note(s) from each unique source*;
    • Review of the result(s) of each unique test*;
    • Ordering of each unique test*;
    • Assessment requiring an independent historian(s)
or
Category 2: Independent Interpretation of tests
  • Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported);
or
Category 3: Discussion of management or test intepretation
  • Discussion of management or test intepretation with external physician/other qualified health care professional\appropriate source (not separately reported)
Moderate risk of morbidity from additional diagnostic testing or treatment
Examples only:
  • Prescription drug management
  • Decision regarding minor surgery with identified patient or procedure risk factors
  • Decision regarding elective major surgery without identified patient or procedure risk factors
  • Diagnosis or treatment significantly limited by social determinants of health
99205
99215		 High High
  • 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment;
    or
  • 1 acute or chronic illness or injury that poses a threat to life or bodily function
Extensive
(Must meet requirements of at least 2 out of 3 categories)
Category 1: Tests, documents, or independent historian(s)
  • Any combination of 3 from the following:
    • Review of prior external note(s) from each unique source*;
    • Review of the result(s) of each unique test*;
    • Ordering of each unique test*;
    • Assessment requiring an independent historian(s)
or
Category 2: Independent Interpretation of tests
  • Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported);
or
Category 3: Discussion of management or test interpretation
  • Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported)
High risk of morbidity from additional diagnostic testing or treatment
Examples only:
  • Drug therapy requiring intensive monitoring for toxicity
  • Decision regarding elective major surgery with identified patient or procedure risk factors
  • Decision regarding emergency major surgery
  • Decision regarding hospitalization
  • Decision not to resuscitate or to de-escalate care because of poor prognosis

Elements of Medical Decision Making

Level of MDM (Based on 2 out of 3 Elements of MDM)

Number and Complexity of Problems Addressed at the Encounter

Amount and/or Complexity of Data to be Reviewed and Analyzed
Each unique test, order, or document contributes to the combination of 2 or combination of 3 in Category 1 below.

Risk of Complications and/or Morbidity or Mortality of Patient Management
Straightforward Minimal
  • 1 self-limited or minor problem
Minimal or none Minimal risk of morbidity from additional diagnostic testing or treatment
Low Low
  • 2 or more self-limited or minor problems;
    or
  • 1 stable chronic illness;
    or
  • 1 acute, uncomplicated illness or injury;
    or
  • 1 stable, acute illness;
    or
  • 1 acute, uncomplicated illness or injury requiring hospital inpatient or observation level of care
Limited
(Must meet the requirements of at least 1 of the 2 categories)
Category 1: Tests and documents
  • Any combination of 2 from the following:
    • Review of prior external note(s) from each unique source*;
    • review of the result(s) of each unique test*;
    • ordering of each unique test*
or
Category 2: Assessment requiring an independent historian(s)
(For the categories of independent interpretation of tests and discussion of management or test interpretation, see moderate or high) 		Low risk of morbidity from additional diagnostic testing or treatment
Moderate Moderate
  • 1 or more chronic illnesses with exacerbation progression, or side effects of treatment;
    or
  • 2 or more stable chronic illnesses;
    or
  • 1 undiagnosed new problem with uncertain prognosis;
    or
  • 1 acute illness with systemic symptoms;
    or
  • 1 acute complicated injury
Moderate
(Must meet the requirements of at least 1 out of 3 categories)
Category 1: Tests, documents, or independent historian(s)
  • Any combination of 3 from the following:
    • Review of prior external note(s) from each unique source*;
    • Review of the result(s) of each unique test*;
    • Ordering of each unique test*;
    • Assessment requiring an independent historian(s)
or
Category 2: Independent Interpretation of tests
  • Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported);
or
Category 3: Discussion of management or test intepretation
  • Discussion of management or test intepretation with external physician/other qualified health care professional\appropriate source (not separately reported)
Moderate risk of morbidity from additional diagnostic testing or treatment
Examples only:
  • Prescription drug management
  • Decision regarding minor surgery with identified patient or procedure risk factors
  • Decision regarding elective major surgery without identified patient or procedure risk factors
  • Diagnosis or treatment significantly limited by social determinants of health
High High
  • 1 or more chronic illnesses with severe exacerbation, progression, or side effects of treatment;
    or
  • 1 acute or chronic illness or injury that poses a threat to life or bodily function
Extensive
(Must meet requirements of at least 2 out of 3 categories)
Category 1: Tests, documents, or independent historian(s)
  • Any combination of 3 from the following:
    • Review of prior external note(s) from each unique source*;
    • Review of the result(s) of each unique test*;
    • Ordering of each unique test*;
    • Assessment requiring an independent historian(s)
or
Category 2: Independent Interpretation of tests
  • Independent interpretation of a test performed by another physician/other qualified health care professional (not separately reported);
or
Category 3: Discussion of management or test interpretation
  • Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source (not separately reported)
High risk of morbidity from additional diagnostic testing or treatment
Examples only:
  • Drug therapy requiring intensive monitoring for toxicity
  • Decision regarding elective major surgery with identified patient or procedure risk factors
  • Decision regarding emergency major surgery
  • Decision regarding hospitalization or escalation of hospital-level care
  • Decision not to resuscitate or to de-escalate care because of poor prognosis
  • Parenteral controlled substances

RISK LEVEL

DIAGNOSTIC TESTING

TREATMENT OPTIONS

N/A
  • N/A
  • N/A

Minimal
  • Laboratory tests requiring venipuncture
  • Chest X-rays
  • EKG/EEG
  • Urinalysis
  • Ultrasound (e.g. Echocardiography)
  • KOH prep
  • Rest
  • Gargles
  • Elastic bandages
  • Superficial dressings
  • Other Minimal risk testing or treatment______________

Low
  • Physiologictests 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
  • Other Low risk testing or treatment ______________

Moderate
  • Physiologictests 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, culdocentesis)
  • Prescription drug management
  • Decision regarding minor surgery, with identified patient or procedure risk factors
  • Decision regarding elective major surgery (open, percutaneous, or endoscopic), without identified patient or procedure risk factors
  • Therapeutic nuclear medicine
  • IV fluids, with additives
  • Closed treatment of fracture or dislocation, without manipulation
  • Diagnosis or treatment significantly limited by social determinants of health
  • Other Moderate risk testing or treatment____________________________

High
  • Cardiovascular imaging, with contrast, with identified risk factors
  • Cardiac electrophysiological tests
  • Diagnostic endoscopies, with identified risk factors
  • Drug therapy requiring intensive monitoring for toxicity
  • Decision regarding elective major surgery (open, percutaneous, endoscopic), with identified patient or procedure risk factors
  • Decision regarding emergency major surgery (open, percutaneous, endoscopic)
  • Decision regarding hospitalization or escalation of hospital level of care
  • Decision not to resuscitate, or to de-escalate care because of poor prognosis
  • Parenteral controlled substances
  • Other High risk testing or treatment ______________
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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