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EVALUATION AND MANAGEMENT DOCUMENTATION GUIDELINES:

HISTORY EXAM
CODE LEVEL History Present Illness Review of Systems (14 Past, Family and Social Body Areas (7 possible elements) or
(8 possible elements) possible elements) History (3 elements) Organ Systems (12 possible elements)
Problem Focused 1 to 3 None None 1 Limited Area/System

Expanded Problem 1 to 3 1 None 1 Limited Area/System + other system


Focused
Detailed 4 to 8 2 to 9 1 1 Extended Area/System + other system

Comprehensive 4 to 8 10 to 14 2 (Established patients) or >7 Systems or Complete 1 System


3 (New patients)

ELEMENTS:
HISTORY OF PRESENT REVIEW OF SYSTEMS: BODY AREAS: ORGAN SYSTEMS:
ILLNESS: Constitutional, Head/Face Constitutional
Location Eyes Neck Eyes
Quality ENT Chest ENT
Severity Cardiovascular Abdomen Cardiovascular
Duration Respiratory Genitalia Respiratory
Timing GI Back/Spine GI
Context GU Each Extremity GU
Modifying factors Musculoskeletal Musculoskeletal
Associated signs & symptoms Skin Skin
Neurological Neurologic
Psychiatric Psychiatric,
Endocrine, Hematologic/Lymphatic/
Hematologic/Lymphatic Immunologic
Allergic/Immunologic

Decision Making Elements (2 of 3) Risk Elements


Decision Making Number of Diagnoses or Amount/complexity of Risk of Complications Presenting Problem Diagnostic Procedures Management Options
Management Options Data to be reviewed or Morbidity/Mortality Selected
Straightforward Minimal 1 Minimal or None Minimal 1 Self Limited or Minor Blood work Rest
Plain X-rays

Low Complexity Limited 2 Limited Low 2 Self Limited or Minor Arthrocentesis OTC Drugs
1 Stable Chronic Illness Physiologic Tests w/o Stress Simple Injections
Acute Uncomplicated Injury/Ill PT/OT
Moderate Complexity Multiple 3 Moderate Moderate 1 Chronic Exacerbation Myelogram Prescription Drugs
2 Stable Chronic Illness Physiologic Tests w/Stress Complex Injections
Undiagnosed New Problem Minor Surgery w/risk factors
Acute Complicated Injury/Ill Major Surgery no risk factors
High Complexity Extensive 4 Extensive High 1 Chronic severe Exacerbation Discography Drugs monitor for toxicity
Acute/Chronic Ill/Injury w/threat to IM/IV Controlled Drugs
life body function Major Surgery w/risk factors
Abrupt change neuro status
INITIAL EVALUATIONS
NEW OFFICE VISIT 99201 99202 99203 99204 99205
Time 10 minutes 20 minutes 30 minutes 45 minutes 60 minutes
OUTPAT CONSULT 99241 99242 99243 99244 99245
Time 15 minutes 30 minutes 40 minutes 60 minutes 80 minutes
CONFIRM CONSULT 99271 99272 99273 99274 99275
Time 15 minutes 30 minutes 40 minutes 60 minutes 80 minutes
INPAT CONSULT 99251 99252 99253 99254 99255
Time 20 minutes 40 minutes 55 minutes 80 minutes 110 minutes
INPAT H&P NA NA 99221 99222 99223
Time

HISTORY Problem Expand Problem Detailed Comprehensive Comprehensive


Focused Focused
HPI 1 to 3 1 to 3 4 to 8 4 to 8 4 to 8
ROS None 1 2 to 9 10 to 14 10 to 14
PFSH None None 1 2 to 3 3

EXAM Problem Expand Problem Detailed Comprehensive Comprehensive


Focused Focused
Body Areas or Organ 1 Limited 1 Limited + 1 1 Extended + 1 >7 Systems or >7 Systems or
other system other system Complete 1 Complete 1
Systems system system

DECISION MAKING Straightforward Straightforward Low Complexity Moderate High Complexity


Complexity
No Dx/Mgt Options Minimal 1 Minimal 1 Limited 2 Multiple 3 Extensive 4
Amt/Complexity Data Minimal or None Minimal Limited Moderate Extensive
Risk Minimal Low Low Moderate High

SUBSEQUENT EVALUATIONS
EST OFFICE VISIT 99211 99212 99213 99214 99215
Time 5 minutes 10 minutes 15 minutes 25 minutes 40 minutes

HISTORY None Problem Expand Problem Detailed Comprehensive


Focused Focused
HPI 0 1 to 3 1 to 3 4 to 8 4 to 8
ROS None None 1 2 to 9 10 to 14
PFSH None None None 1 3

EXAM None Problem Expand Problem Detailed Comprehensive


Focused Focused
Body Areas or Organ 0 1 Limited 1 Limited + 1 1 Extended + 1 >7 Systems or
other system other system Complete 1
Systems system

DECISION MAKING None Straightforward Low Complexity Moderate High Complexity


Complexity
No Dx/Mgt Options None Minimal 1 Minimal 1 Limited 2 Extensive 4
Amt/Complexity Data None Minimal or None Minimal Limited Extensive
Risk None Minimal Low Low High