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Patient Facility DOB Encounter Date Chief Complaint is required in ALL documentation Criteria Status of 1-2 Chronic Conditions OR Status of 1-2 Chronic Conditions OR MRN History Components HPI (History of Present Illness) Status of 3 chronic problems 1 2 3 Status of 3 Chronic Conditions OR Status of 3 Chronic Conditions OR Choose Elements Quality Location Duration Severity Timing Context Modifying factors Associated Signs/Symptoms ROS (Review of Systems) Constitutional ENT Eyes CV Skin/Breasts Resp Endo GI GU Heme/Lymph MS Neuro Psych Allergy/Immunology PFSH (Past Medical, Family Social History) Past History (Illnesses, Surgeries, Injuries) Past Family (Diseases, Hereditary illnesses) Social (Review of current, past activities) *Complete PFSH 3 history areas for ALL NEW Patients 2 history areas for ALL Follow Up/Established Visits OR Patients seen in Emergency Department OR Brief 1-3 Elements Brief 1-3 Elements Pertinent to Problem Extended ≥4 Elements Extended (Pertinent to problem and other related systems) 2-9 Total Extended ≥4 Elements Complete (Pertinent and all related systems) NA 1 NA NA 10 Total Pertinent *Complete 1 Area PROBLEM FOCUSED EXPANDED PROBLEM FOCUSED DETAILED 2-3 Areas COMPREHENSIVE ALL Criteria for selected level MUST be MET or EXCEEDED Examination Exam description Limited to affected body area or organ system Affected body area/organ system and other symptomatic or related organ systems Extended exam of affected body areas/organ systems and other symptomatic or related organ systems General Multi-System Complete Single Organ System 1995 Guideline 1997 Guideline Type of Exam 1 Body Area or Organ System 1-5 Bulleted Items PROBLEM FOCUSED EXPANDED PROBLEM FOCUSED 6-11 or more 2-7 12-17 or more for 2 or more systems 18 or more for 9 or more systems Refer to Guideline 2-7 ≥8 Not Defined DETAILED COMPREHENSIVE See 1995 or 1997 Guidelines for Evaluation & Management Services for specific requirements 1 FREE Medical Documentation Tool brought to you by The Folks at MedicalTemplates Patient Facility DOB Encounter Date MRN A. Complexity of Medical Decision Making Number of Diagnoses or Treatment Options Problem (Status) Self-limited or minor (stable, improved or worsening) Est. problem (to examiner) stable, improved Est. problem (to examiner) worsening New problem (to examiner) no additional workup planned New problem (to examiner) additional workup planned MDM = Medical Decision Making (Number x Number Max = 2 Max = 1 Check corresponding box below on Line A Final Result for Complexity of MDM Points Points 1 1 2 3 4 Total = Result) Result B. Amount and/or Complexity of Data Reviewed Reviewed Data Review and/or Order of lab tests Review and/or Order of tests in the radiology section of CPT Review and/or Order of tests in the medicine section of CPT Discussion of test results with performing physician Decision to obtain old records and/or obtain history from someone other than the patient Review and summarization of old records and/or obtaining history from someone other than the patient and/or discussion of case with another health care provider Independent visualization of image, specimen or tracing (NOT simply review of report) Points 1 1 1 1 1 2 2 Check corresponding box below on Line B of Final Result for Complexity of MDM MDM = Medical Decision Making TOTAL C. Risk of Complications, Morbidity and/or Mortality Risk Min Choose highest risk level and select corresponding risk level on line B in Final Result for Complexity Presenting problems Dx procedures ordered Management options 1 minor or self-limited Venipuncture, CXR, EKG, EEG Rest, elastic bandages 2 or more minor 1 stable chronic problem Acute uncomp illness/injury Mild exac 1 chron prob Physiol tests NOT under stress Non CV imaging with contrast Superficial needle biopsies Physiologic tests under stress Dx endoscopies NO risk factors Deep needle or incisional bx CV imaging + contrast Obtain fluid from body cavity CV imaging + contrast, risk factors Card electrophysiologic studies Dx endoscopies + risk factors Discography OTC drugs, PT, OT IV fluids without additives Minor surgery NO risk factors Minor surgery + risk factors Mod Elective major surgery 2 stable chron prob Prescription drug therapy Acute illness + systemic Sx Therapeutic nuclear medicine Acute complicated injury IV fluids + additives Elective maj surg + risk factors High Sev exac, 1 chron prob Emergency major surgery Acute or chronic illness Parenteral controlled sub posing threat to life/limb Rx requiring intense monitoring Abrupt change neuro status DNR or de-escalation of care Check corresponding box below on Line C of Final Result for Complexity of MDM Low Final Result for Complexity of Medical Decision Making The column with 2 or 3 circles determines overall complexity of Medical Decision Making A B C Number Tx Options See TOTAL above in Box A Amount of Data See TOTAL above in Box B Highest Risk See Box C Above 1 or less Minimal 1 or less Minimal Minimal 2 Limited 2 Limited Low 3 Multiple 3 Multiple Moderate 4 Extensive 4 Extensive High Decision Making Level SF Low Moderate High 2 FREE Medical Documentation Tool brought to you by The Folks at MedicalTemplates Patient Facility DOB Encounter Date MRN OVERALL OUTPATIENT ENCOUNTER LEVEL New Office / Consult / ER History Exam Complexity Medical Decision LEVEL Requires 3 components within shaded area PF EPF D C ER: PF ER: EPF ER: EPF ER: D PF EPF D C ER: P ER: EPF ER: EPF ER: D SF SF L M ER: SF ER: L ER: M ER: M C ER: C C ER: C H ER: H Established Office Requires 2 components within shaded area Minimal PF EPF D problem that may PF EPF D not require SF L M presence of physician C C H I II III IV V I II III IV V PF = Prob focused EPF = Expanded prob focused D = Detailed C = Comprehensive SF = Straightforward L = Low complexity M = Moderate complexity H = High complexity OVERALL INPATIENT ENCOUNTER LEVEL History Exam Complexity Medical Decision LEVEL Initial Hosp Encounter or Observation D or C C C D or C C C SF / L M H I II III Subsequent Inpatient or Follow Up PF EPF D PF EPF D SF / L M H I II III PF = Prob focused EPF = Expanded prob focused D = Detailed C = Comprehensive SF = Straightforward L = Low complexity M = Moderate complexity H = High complexity Time If ALL responses regarding time are “Yes”, billing may be based on Time “If the physician documents total time and suggests 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 or discussion with another health care provider.” Does documentation reveal total time? Must be face-to-face (Outpatient or Inpatient) Does documentation discuss the content of counseling or coordination of care? Does documentation reveal that more than half the time was spent on counseling or coordination of care? □Yes □No □Yes □No □Yes □No References 1997 Guidelines for Evaluation and Management Services http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf HGSAdministrators Documentation Worksheet www.aace.com/advocacy/pdf/AUDITTOOLMEDICARE.pdf Evaluation and Management Coding and Documentation Reference Guide Trailblazer Health Enterprises, LLC 3 FREE Medical Documentation Tool brought to you by The Folks at MedicalTemplates