1997 Evaluation and Management Services Coding Tool (General Multi-System) Rev. 4/11/08

1997 Evaluation and Management Services Coding Tool (General Multi-System) Rev. 4/11/08

 Chief Complaint /  New Patient  Est Patient  Consultation
HISTORY
HPI (History of Present Illness)
 Location  Duration  Mod. Factors  Quality  Severity
 Timing  Context  Associated signs & symptoms
ORStatus of chronic/inactive conditions 1  2  3  / 
Brief
(1-3 elements, or status of 1-2 chronic conditions) / 
Extended
(4 or more elements, or status of 3 chronic or inactive conditions)
ROS (Review of Systems)
Constitutional  Eyes  ENMT  Card/vasc  Neuro GI
Musculo  Resp GU  Hem/Lymph  Psych
All/imm Integ Endo / 
None / 
Pertinent to problem
(1 system) / 
Extended
(2-9 systems including 1 pertinent) / 
Complete
(10 or more systems including 1 pertinent)
PFSH (Past medical, Family and Social History)
Past (patient’s illnesses, operation, injuries & treatments)
Family (review of medical events in pt’s family incl. hereditary disease placing pt at risk)
 Social (age appropriate review of past & current activities)
* Complete PFSH:
2 Hx areas: a) Established pts. - office visit; domiciliary care; home care; b) Emergency dept. visit; and, c) Subsequent nursing facility care.
3 Hx areas: a) New patients. - office visit; domiciliary care; home care; b) Consultations; c) Initial hospital care; d) hospital observation; and, e) Comprehensive nursing facility assessments. / 
None / 
Pertinent
(1 history area) / 
Complete
New or Consult :
3 history areas
Established:
2 history areas
Problem-Focused
(PF) / Expanded Problem Focused (EPF) / Detailed (D) / Comprehensive ( C )
Final level of history requires 3 components above met or exceeded
EXAMINATION
Constitutional:
 Vital Signs: Any 3 of the following: 1) Sitting BP or standing BP, 2) supine BP, 3) pulse rate / regularity, 4) respiration, 5) temperature, 6) height, 7) weight
 General Appearance: (eg Development, nutrition, body habitus, deformities, attention to grooming, etc.) / 
1-5 elements / 
6-11 elements / 
Includes at least 6 organ systems or body areas; for each system/area selected, document at least 2 elements identified by a bullet ()
OR
12 or more elements identified by a bullet () in 2 or more organ systems/body areas / 
Includes at least 9 organ systems or body areas; for each system/area selected, document at least 2 elements identified by a bullet ()
.
Eyes: Inspection of conjunctivae and lidsExamine pupils and irises (eg reaction to light accommodation, size, and symmetry) Ophthalmoscopic exam of optic discs (size, C/D ratio, appearance) and posterior segments (eg vessel changes, exudates, hemorrhages)
ENMT: External inspection ears and nose (eg overall appearance, scars, lesions, masses)
Otoscopic exam – ext. auditory canals & TMs’; Assess hearing (eg whispered voice, finger rub, tuning fork) Inspect nasal mucosa, septum, turbinates; Inspect teeth, gums;
Inspectionof oropharynx (eg oral mucosa, salivary glands, hard & soft palates, tongue, tonsils, posterior pharynx)
Neck: Examine neck (eg masses, symmetry, tracheal position, crepitus, overall appearance)
 Examination of thyroid (eg, enlargement, tenderness, mass)
Respiratory: Assessment of respiratory effort (eg intercostal retractions, use of accessory muscles, diaphragmatic movement) Chest percussion (eg dullness, flatness, hyperresonance) Chest palpation (tactile fremitus)  Auscultation of lungs (eg breath sounds, adventitious sounds, rubs)
Cardiovascular: Palpation of heart (eg, location, size, thrills)
 Auscultation of heart including sounds, abnormal sounds and murmurs
Examination of
Carotid arteries (eg, waveform, pulse amplitude, bruits, apical-carotid delay)
Abdominal aorta (eg, size, bruits)
Femoral arteries (eg, pulse amplitude, bruits)
Pedal pulses (eg, pulse amplitude)
Extremities for edema and/or varicosities
Chest (Breasts)
Inspection (eg symmetry, nipple discharge)
Palpation of breasts & axillae (eg masses, lumps, tenderness)
GI/AbdomenExamination of abdomen with notation of presence of masses or tenderness
Examination of liver and spleenExamination presence/absence hernia
Exam (when indicated) anus, perineum, rectum (including sphincter tone, +/- hemorrhoids &/or masses)
Stool sample for occult blood test (when indicated)
GU- Male: Scrotum(hydrocele, spermatocele, cord tenderness, testicular mass)  Penis Digital rectal exam of prostate(size, symmetry, nodularity, tenderness)
GU- Female: Pelvic exam (with or w/o specimen collection for smear/cultures): External genitalia and vagina(eg general appearance, hair distribution, lesions, estrogen effect, discharge, pelvic support, cystocele, rectocele)  Urethra(eg masses, tenderness, scarring) Bladder(eg fullness, masses, tenderness)  Cervix(eg general appearance, lesions, discharge)  Uterus (eg size, contour, position, mobility, tenderness, consistency, descent or support)  Adnexa/parametria(eg masses, tenderness, organomegaly, nodularity)
Lymphatic
Palpation of lymph nodes in 2 or more areas: neck, axillae, groin, and/or other location
Skin
Inspection and palpation of skin and subcutaneous tissue (eg, rashes, lesions, scars, induration, subcutaneous nodules, tightening)
Musculoskeletal:
 Gait & Station
Digits & Nails: Inspection and palpation (eg, clubbing, cyanosis, inflammation,petechiae, ischemia, infections, nodes)
Joint/Bone/Muscle exam of 1 or more of the following 6 areas: 1) Head & neck; 2) Spine, ribs, & pelvis; 3) Rt. Upper extremity; 4) Lt. upper extremity; 5) Rt. Lower extremity; 6) Lt. lower extremity. Exam of a given area includes:

Inspect/palpate, noting any misalignment, asymmetry, crepitus, defects, tenderness, masses, effusions
Assess ROM, noting any pain, crepitus, or contracture
Assess stability, noting any dislocation, subluxation, or laxity
Assess muscle strength/tone, noting any atrophy or abnormal movements

Neurological: Test cranial nerves, noting any deficits Examine DTR’s, noting any pathological reflexes  Examine sensation (eg touch, pin, vibration, propioception) / Problem Focused
(PF) / Expanded Problem Focused (EPF) / Detailed
(D) / Comprehensive
(C)
Psychiatric:Description of patient’s judgment and insight
Brief assessment of mental status including Orientation to time, place and person Recent & remote memory  Mood and affect (eg, depression, anxiety, agitation)
MEDICAL DECISION MAKING
A.1 Number of Diagnoses and/or Management Options
NOTE: A “problem” is defined as a definitive diagnosis, or, for undiagnosed problems, a related group of presenting symptoms and/or clinical findings / # Dxs
EACH new or established problem for which the diagnosis and/or treatment plan is evident with or without diagnostic confirmation / Per Problem
1 point
EACH new or established problem for which the diagnosis and/or treatment plan is not evident; 2 plausible differential diagnoses, comorbidities, or complications (not counted as separate problems) clearly stated and supported by information in record; requiring diagnostic evaluation or confirmation / Per Problem
2 points
EACH new or established problem for which the diagnosis and/or treatment plan is not evident; 3 plausible differential diagnoses, comorbidities, or complications (not counted as separate problems) clearly stated and supported by information in record; requiring diagnostic evaluation or confirmation / Per Problem
3 points
EACH new or established problem for which the diagnosis and/or treatment plan is not evident; 4 plausible differential diagnoses, comorbidities, or complications (not counted as separate problems) clearly stated and supported by information in record; requiring diagnostic evaluation or confirmation / Per Problem
4 points
Total Diagnoses (Box A1)(If total is greater than total points for Box A2, use in Box D)
A.2 Treatments and Therapeutic Options / Pts / BOX B. Amount and/or Complexity of Data Reviewed or Ordered / Pts
Continue “same” therapy or “no change” in therapy (including drug management) if specified therapy is not described in documentation and documented that the physician reviewed therapy) / 0 / Order and/or review of medically reasonable and necessaryclinical lab tests ( 1 lab panel = 1 procedure) / 1-3 procedures: 1 pt
≥ 4 procedures: 2 pts
Order and/or review results of medically reasonable and necessary tests in Radiology section of CPT / 1-3 procedures: 1 pt
≥ 4 procedures: 2 pts
Drug management, per problem. Includes “same” therapy or “no change” in therapy if specified therapy is described (document current therapy + that provider reviewed it). Record must reflect conscious decision-making to make no-dose changes in order to count for coding purposes. / ≤ 3 new or current meds per problem / 1 pt Per Problem / Order and/or review results of medically reasonable and necessary tests in Medicine section of CPT / 1-3 procedures:1 point
≥ 4 procedures: 2 points
3 new or current meds per problem / 2 pts Per Problem / Discuss case with other physician managing patient’s care or request consult from other physician (referral does not count) / 1
Major or Minor surgical procedure(s) / 1 / Discuss test results with performing physician / 1
Closed treatment for fracture/dislocation
Physical therapy, occupational therapy, speech therapy, or other manipulation / 1
1 / Order or review old records. Record type/source must be documented. Review must be reasonable + necessary based on patient’s condition. Practice/facility protocol driven review, or review only for coding is not permitted. / Without summary:
1 point
With summary:
2 points / 1
Complex insulin Rx (SC or combo), hyperalimentation, insulin drip, or other complex IV admix Rx
IV fluid/fluid component replacement, establish IV access when record is clear that such involved physician decision-making and wasn’t standard facility “protocol” / 2
1 / Review of significant physiologic monitoring or testing data not reported for separate payment / 1
Pain management procedure
Joint, body cavity, soft tissue, etc. injection/aspiration / 1
1 / Independently visualization and interpretation of an image, EKG, or lab specimen not reported for separate payment / Each visualization and interpretation
= 1 point / 1
Conservative measures such as rest, ice bandages, dietary
Patient educated on self or home care topics/techniques / 1
1 / TOTAL for Box B (Bring results to BOX D)
Decision to admit to hospital / 1
Discuss case with other physician / 1
Other-specify / 1
Total Management Options (Box A2) (If total is total points for Box A1, use in Box D)
C. Risk of Complications and/or Morbidity or Mortality
C.1 Levels of Risk
Level of Risk / Nature of Presenting Illness/Problem(s) / Diagnostic Procedure Ordered / Management Options Selected
Minimal /

One self-limited or minor problems; e.g., cold, insect bite, tinea corporis

Laboratory tests requiring venipuncture
Chest x-rays
EKG/EEG
Urinalysis
Ultrasound, e.g., echocardiography

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 non-insulin dependent diabetes, cataract, BPH
Acute uncomplicated illness or injury; e.g., cystitis, allergic rhinitis, simple sprain

/ Physiological tests not under stress;
e.g., pulmonary function tests
Non-cardiovascular 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 illnesses 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 w/contrast and no identified risk factors, e.g., arteriogram, cardiac catheterization
Obtain fluid from body cavity, e.g., lumbar puncture thoracentesis, culdocentesis

/ Minor surgery w/ identified risk factors

Elective major surgery (open, percutaneous, or endoscopic) w/ 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 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., seizures, 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
Decisions not to resuscitate or to de-escalate care because of poor prognosis

Final risk is determined by the highest of the 3 components above – take highest level to Box D
BOX D. Final Result for Complexity of Medical Decision-Making (MDM)
Box A / Number of diagnoses and/or management options /

1 point – Minimal

2 points - Limited

/ 3 points – Multiple /

≥ 4 points - Extensive

Box B / Amount and complexity of data reviewed or ordered /

1 point - None/Minimal

2 points - Limited

/ 3 points – Multiple /

≥ 4 points - Extensive

Box C / Risk of complications and/or morbidity or mortality /

Minimal

Low

Moderate

/ High
Type of Medical decision-making /

Straightforward

/ Low Complexity /

Moderate Complexity

High Complexity

Final MDM requires that 2 of 3 of the above components are met or exceeded
Evaluation and Management (E/M) Level of Service
New Pt Outpatient Visit Requires 3 of 3 components met / Consult Outpatient Visit Requires 3 of 3 components met
E/M Code / History / Exam / MDM / Average Time / E/M Code / History / Exam / MDM / Average Time
99201 / PF / PF / S / 10 / 99241 / PF / PF / S / 15
99202 / EPF / EPF / S / 20 / 99242 / EPF / EPF / S / 30
99203 / D / D / L / 30 / 99243 / D / D / L / 40
99204 / C / C / M / 45 / 99244 / C / C / M / 60
99205 / C / C / H / 60 / 99245 / C / C / H / 80
Established Pt Outpatient Visit : Requires 2 of 3 components met; 1 must be MDM / ER Visit Requires 3 of 3 components met
99211 / NA / NA / NA / 5 / 99281 / PF / PF / S / NA
99212 / PF / PF / S / 10 / 99282 / EPF / EPF / L / NA
99213 / EPF / EPF / L / 15 / 99283 / EPF / EPF / M / NA
99214 / D / D / M / 25 / 99284 / D / D / M / NA
99215 / C / C / H / 40 / 99285 / C / C / H / NA
TIME
If the attending physician documented that the visit was dominated (more than 50%) by counseling or coordinating care, time may be used to determine the level of service. In addition to any history, examination or MDM documented, documentation must include the total visit time, counseling/coordination of care time, and details of the counseling/coordination of care. Details may include prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, etc. If all the answers to the below 3 questions are “yes”, the total visit time may be used to select the level of the service.
Does the attending physician’s documentation indicate the total face-to-face visit time? / □ Yes □ No
Does the attending physician’s documentation indicate that more than 50% of the time was counseling or coordinating the patient’s care? / □ Yes □ No
Does documentation describe the content of counseling or coordinating the patient’s care? / □ Yes □ No