¡Descarga Medical Coding ENSIGN y más Diapositivas en PDF de Psicología Social solo en Docsity!
A CMS Medicare Administrative Contractor
National Government Services, Inc. 1074_0317 Page: 1 of 6
Evaluation & Management Documentation Training Tool
1—History
Refer to the data section (below) in order to quantify. After referring to data, circle the entry farthest to the RIGHT in the table, which best describes the history of present illness (HPI), review of
system (ROS), and past medical, family, social history (PFSH). If one column contains three circles, draw a line down that column to the bottom row to identify the type of history. If no column
contains three circles, the column containing a circle farthest to the LEFT, identifies the type of history. After completing this table which classifies the history, circle the type of history within the
appropriate grid in Section 5. Minimum requirements for each level of history are listed directly above each level in the grid. CHIEF COMPLAINTS REQUIRED FOR ALL HISTORY LEVELS.
HPI Elements Calculation
Location Quality
Severity Duration
Timing Context
Modifying factors Associated signs and symptoms Brief (1-3)^ Brief^ (1-3)^
Extended (4 or more)
Extended (4 or more)
HPI: Status of Chronic Conditions
N/A N/A
Status of 3 chronic conditions
Status of 3 chronic 3 conditions^ conditions
ROS: (Review of Systems)
None
Pertinent to Problem (1 system)
Extended (2–9)
Complete
Complete ROS : Ten or more systems, or some systems with statement “all others negative.”
Constitutional (weight loss, etc.) Eyes
Ears, nose, mouth, and throat Card/Vascular Respiratory
GI
GU
Musc\Skeletal Integumentary (Skin, breast)
Neuro Psych
Endo
Hem Lymph All/immuno All others negative
PFSH (past medical, family, social history) areas
None None
Pertinent to Problem (1 history area)
Complete (2 or 3 history area)
Complete PFSH Two history areas : a) Established patients – office (outpatient) care; b) Emergency dept.
Three history areas : a) New patients – office (outpatient) care, domiciliary care, home care; b) Initial hospital care; c) Hospital observation; d) Initial nursing facility care.
Past history (patient’s past experiences with illnesses, operations, injuries and treatments)
Family history (a review of medical events in the patient’s family, including diseases which may be hereditary or place the patient is at risk)
Social history (an age-appropriate review of past and current activities)
Note : For subsequent hospital and nursing facility E&M services, only an interval history is necessary. It is unnecessary to record information about the PFSH.
Final Results
Problem Focused
Expanded Problem Focused Detailed^ Comprehensive
2—Examination
Refer to data section (table below) in order to quantify. After referring to data, identify the type of examination. Circle the type of examination within the appropriate grid in Section 5.
Note: Choose 1995 or 1997 rules, but not both.
Examination Calculation – Choose either 1995 or 1997 rules to calculate result
Body areas: Head, including face Chest, including breast and axillae Abdomen Neck Back, including spine Genitalia, groin, buttocks Each extremity
Organ systems: Constitutional (e.g., vitals, gen app) Ears, nose. mouth, throat Respiratory GI GU Cardiovascular Musculoskeletal Skin Neuro Psych Hem/lymph/imm Eyes
One body area or system
2-7 areas or systems (Minimal detail for areas and/or systems examined; check list type documentation without any expansion of documentation of findings)
2-7 areas or systems (Expanded documentation of the areas and/or systems examined; requires more than checklists; needs to have normal/abnormal findings expanded upon)
8 or more systems only
1-5 bullets (1 or more body areas or system)
6 bullets (1 or more body areas or system)
12 bullets in 2 or more body areas/systems or 2 bullets in 6 or more body areas/ systems (except eye and psych exams, which are 9 bullets)
2 bullets in 9 or more body areas or systems; or complete single organ system
Final Results Problem Focused Expanded Problem Focused Detailed Comprehensive
Risk of Complications and/or Morbidity or Mortality
Use the risk table below as a guide to assign risk factors. It is understood that the table below does not contain all specific instances of medical care; the table is intended to be used as a guide.
Circle the most appropriate factor(s) in each category. The overall measure of risk is the highest level circled. Enter the level of risk identified in “Final Result for Complexity” table below.
Table 3C
Level of Risk Presenting Problem(s) Diagnostic Procedure(s) Ordered 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., echo - 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 hypertension or
- noninsulin dependent diabetes, cataract, BPH
- Acute uncomplicated illness or injury, e.g., cystitis, allergic rhinitis, simple sprain - Physiologic tests not under stress, e.g., pulmonary function tests - Noncardiovascular imaging studies with contrast, e.g., barium enema - Superficial needle biopsies - Clinical laboratory tests requiring arterial 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, 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 - 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 with contrast and no identified risk factors, e.g., arteriogram cardiac catheter - 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 (continuation & new prescription) - Therapeutic nuclear medicine - IV fluids with additives - Closed treatment of fracture or dislocation without manipulation
High
- One or more chronic illnesses with severe exacerbation, 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., seizure, TIA, weakness or sensory loss - Cardiovascular imaging studies with contrast with identified risk factors - Cardiac electrophysiological tests - Diagnostic endoscopies with identified risk factors - Discography - 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 - Decision not to resuscitate or to de-escalate care because of poor prognosis
Final Result for Complexity
Table 3D
A Number diagnoses or treatment options ≤ 1 Minimal 2 Limited 3 Multiple ≥ 4 Extensive
B Amount and Complexity of Data ≤ 1 Minimal 2 Limited 3 Moderate ≥ 4 Extensive C Highest Risk Minimal Low Moderate High
Type of decision making Straight Forward Low Complexity Moderate Complexity High Complexity
Draw a line down any column with 2 or 3 circles to identify the type of decision making in that column. Otherwise, draw a line down the column with the second circle from the left. After completing this table, circle the type of decision making within the appropriate grid in Section 5.
4—Time
If the physician documents total time and indicates that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer
to: prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk reduction and/or discussion with another health care provider
Question Answer
Does documentation reveal total time? Yes No Does documentation describe the content of counseling or coordinating care? Yes No
Does documentation reveal that more than half of the time was counseling or coordinating care? Yes No
5—Level of Service
Outpatient and Emergency Room (ER)
New Office/ER —Requires three components within shaded area Established Office —Requires two components within shaded area History PF ER: PF
EPF
ER: EPF
D
ER: EPF
C
ER: D
C
ER: C
Minimal problem that may not require presence of physician
PF EPF D C
Examination PF ER: PF
EPF
ER: EPF
D
ER: EPF
C
ER: D
C
ER: C
PF EPF D C
Complexity of medical decision
SF
ER: SF
SF
ER: L
L
ER: M
M
ER: M
H
ER: H
SF L M H
Average time (minutes) (ER has no average time)
10 New (99201)
ER (99281)
20 New (99202)
ER (99282)
30 New (99203)
ER (99283)
45 New (99204)
ER (99284)
60 New (99205)
ER (99285)
Level I II III IV V I II III IV V
Inpatient
Initial Hospital/Observation— Requires three components within shaded area Subsequent Hospital— Requires two components within shaded area History D/C C C PF interval EPF interval D interval Examination D/C C C PF EPF D Complexity of medical decision
SF/L M H SF/L M H
Average time (minutes) (Initial observation care has no average time)
30 Init hosp (99221) Observation care (99218)
50 Init hosp (99222) Observation care (99219)
70 Init hosp (99223) Observation care (99220)
Subsequent (99231) Observation (99224)
Subsequent (99232) Observation (99225)
Subsequent (99233) Observation (99226) Level I II III I II III
If all answers are “yes,” you may select level based on time.
