New
Est / 211 / 201
212 / 202
213 / 203
214 / 204
215 / 205
Hx / PF / EPF / D / C / C
HPI / -- / 1 / 1 / 4
3 ChrDz / 4
3 ChrDz / 4
3 ChrDz
ROS / -- / -- / 1 / 2 / 10 / 10
PFSH / -- / -- / -- / 1 / 3/2 / 3
PE / PF / EPF / D / C / C
Bullets / -- / 1 / 6 / 12 / 9S/2B / 9S/2B
MDM / S / S/L / L/M / M/H / H
Diag/Mgt / -- / 1 / 1 / 2/3 / 3/4 / 4
Data / -- / 1 / 1/2 / 2/3 / 3/4 / 4
Risk / -- / min / min/low / low/mod / mod/high / high
Time New
Time Est /
5 / 10
10 / 20
15 / 30
30 / 45
40 / 60

New Patient 3 of 3 (Hx, PE and MDM) must agree

Established Patient (seen within 3 years) 2 of 3 must agree

For MDM 2 of 3 (Dx, Data and/or Risk) must agree

Time can be used if counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter

  • Location - place, whereabouts, site, position. Where on the body is the patient experiencing signs or symptoms? (e.g., pain in groin)
  • Quality - A description, characteristics, or statement to identify the type of sign or symptom. (e.g., burning pain in groin).
  • Severity - Degree, intensity, ability to endure. The patient may describe the severity of their signs or symptoms by using a self-assessment scale to measure subjective levels. (e.g., History of mild burning pain in groin that has become more intense)
  • Duration - Length of time. How long has patient been experiencing the signs or symptoms? (e.g., History of intermittent mild burning pain in groin that has become more intense and frequent for the last two weeks)
  • Timing - Regulation of occurrence. A description of when the patient experiences signs or symptoms (e.g., history of intermittent mild burning pain in groin that has become more intense and frequent for the last two weeks).
  • Context - Circumstances, cause, precursor, outside factors. A description of where the patient is or what the patient does when the signs or symptoms are experienced (e.g., history of intermittent mild burning pain in groin that has become more intense and frequent for the last two weeks since the patient bent down to pick up son and continues to feel intense pain when bending).
  • Modifying Factors - Elements that change, alter or have some effect on the complaint or symptoms (e.g., history of intermittent mild burning pain in groin that has become more intense and frequent for last two weeks since the patient bent down to pick up son; continues to feel intense pain when bending. (Patient currently on Motrin 800 mg BID for past 3 weeks without relief)
  • Associated Signs and Symptoms - Factors or symptoms that accompany the main symptoms. What other factors does patient experience in addition to this discomfort/pain? (e.g., Shortness of breath, lightheadedness, nausea/ vomiting)

Musculoskeletal Examination

System/Body
Area / Elements of Examination
Constitutional /
  • Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured by ancillary staff)
  • General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)

Head and Face
Eyes
Ears, Nose
Mouth and Throat
Neck
Respiratory
Cardiovascular /
  • Examination of peripheral vascular system by observation (eg, swelling, varicosities) and palpation (eg, pulses, temperature, edema, tenderness)

Chest (Breasts)
Gastrointestinal
(Abdomen)
Genitourinary
Lymphatic /
  • Palpation of lymph nodes in neck, axillae, groin and/or other location

Musculoskeletal /
  • Examination of gait and station
Examination of joint(s), bone(s), and muscle(s)/tendon(s) of four of the following six areas: 1) head and neck; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; and 6) left lower extremity. The examination of a given area includes:
  • Inspection, percussion and/or palpation with notation of any misalignment, asymmetry, crepitation, defects, tenderness, masses or effusions
  • Assessment of range of motion with notation of any pain (eg, straight leg raising), crepitation or contracture
  • Assessment of stability with notation of any dislocation (luxation), subluxation or laxity
  • Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements.
NOTE: For the comprehensive level of examination, all four of the elements identified by a bullet must be performed and documented for each of four anatomic areas. For the three lower levels of examination, each element is counted separately for each body area. For example, assessing range of motion in two extremities constitutes two elements.
Extremities / [See musculoskeletal and skin]
Skin /
  • Inspection and/or palpation of skin and subcutaneous tissue (eg, scars, rashes, lesions, cafe-au-lait spots, ulcers) in for of the following six areas: 1) head and neck; 2) trunk; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; and 6) left lower extremity.
NOTE: For the comprehensive level, the examination of all four anatomic areas must be performed and documented. For the three lower levels of examination, each body area is counted separately. For example, inspection and/or palpation of the skin and subcutaneous tissue of two extremities constitutes two elements.
Neurological/
Psychiatric /
  • Test coordination (eg, finger/nose, heel/knee/shin, rapid alternating movements in the upper and lower extremities, evaluation of fine motor coordination in young children)
  • Examination of deep tendon reflexes and/or nerve stretch test with notation of pathological reflexes (eg, Babinski)
  • Examination of sensation (eg, by touch, pin, vibration, proprioception)
Brief assessment of mental status including
  • Orientation to time, place and person
  • Mood and affect (eg, depression, anxiety, agitation)

Content and Documentation Requirements

Level of Exam / Perform and Document
Problem Focused / One to five elements identified by a bullet
Expanded Problem Focused / At least six elements identified by a bullet
Detailed / At least twelve elements identified by a bullet
Comprehensive / Perform all elements identified by a bullet; document every element in each box with a shaded border and at least one element in each box with an unshaded border.

MDM

The elements of medical decision making

Type of
decision making / Diagnoses or
management options / Data to be reviewed / Risk
Straightforward / Minimal (1) / Minimal or none (0-1) / Minimal
Low complexity / Limited (2) / Limited (2) / Low
Moderate complexity / Multiple (3) / Moderate (3) / Moderate
High complexity / Extensive (4) / Extensive (4) / High
At least two criteria must be met or exceeded.
The numbers in parentheses refer to scores derived from the tables "Quantifiying diagnoses and management options" and "Quantifying the amount and complexity of data to be reviewed."

* Risk is not determined by points. Is assigned directly off the risk table

Diagnoses and Management Options

Quantifying diagnoses and management options

Type of problem / Points / Comments
Self-limited or minor / 1 / Add 1 if the patient has two or more such problems.
Established; previously diagnosed / 1 / Add 1 for each additional problem of this type.
Add 1 for each established problem that is inadequately controlled, worsening or failing to progress as expected.
Previously unidentified or undiagnosed when H&P provide enough information. / 3 / Maximum score is 3 for problems of this type, no matter how many the patient has.
Previously unidentified or undiagnosed when you order, plan or perform additional assessment, consultation or diagnostic studies / 4 / One problem of this type is enough to qualify as extensive.

Totals: 1, minimal; 2, limited; 3, multiple; 4, extensive

Data - Based on the amount and complexity of data to be reviewed

Quantifying the amount and complexity of data to be reviewed

Data sources and data-gathering activities / Points
One or more lab tests (CPT codes in the range 80002 - 89399) requested or reviewed / 1
One or more radiology tests or services (CPT codes in the range 70010 - 79999) requested or reviewed / 1
One or more medical diagnostic studies (CPT codes in the range 90701 - 99199) requested or reviewed / 1
Direct visualization and independent interpretation of a specimen, image or tracing previously interpreted by another physician
(May not count if it will be sent out for interpretation) / 1
Discussion of results with the physician who performed or interpreted a study / 1
Decision to obtain old records and/or additional history / 1
Summary of review of old records and/or additional history (not from patient)to supplement that obtained from the patient / 2

Totals: 0-1, minimal or none; 2, limited; 3, moderate; 4, extensive

Risk -The level of risk to the patient is based on
Problem Risk: the number /complexity / uncertainty of diagnoses and prognoses
Diagnostic Procedure Risk: the number and complexity of Diagnostic Procedures to be done
Management Risk: the number/types/complexity of medical interventions and therapeutic procedures utilized
*The highest single element on the entire “risk table” determines the level of risk

Quantifying the risk of complications, morbidity and mortality

Level of risk / 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
  • 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 hypertension or non-insulin-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)
  • 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 with contrast and 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 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 electrophysiologic 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

Risk: ”High” (Dx/ Proc/ Mgt )
Any 1 of the following will qualify:

  • chronic Pb with severe exacerbation
  • Acute Pb life/limb threatening
  • acute neuro/mental status change(TIA, CVA, Sz, weakness)
  • CV contrast studies (with risk factors)
  • endoscopy (with risk factors)
  • elective major surgery (with risk factors)
  • emergent surgery
  • IV narcotics, toxic drugs, requiring monitoring,parenteral treatments
  • Closed treatment of Fx or dislocation with manipulation
  • DNR decision necessitated by condition, not routine discussion

Risk: “Moderate”
Any 1 of the following will qualify:

  • 1 chronic Pb with mild exacerbation
  • 2 chronic stable Pb
  • new Pb, uncertain prognosis
  • acute illness with systemic Sx
  • Physiologic test with stress, angiogram
  • Dx endoscopy without risk factors
  • deep needle/ incisional Bx ; -centesis
  • Rx drug; IV meds; Closed Fx
  • minor surgery with risk factors
  • elective major surgery without risk factors

*If you prescribe any medication from Polytrim eye drops to Atenolol, risk becomes Moderate

Low Risk:

  • 2 or more self limited/minor Pb
  • 1 chronic stable Pb
  • Acute uncomplicated illness/injury
  • Test, non-stress
  • Superficial biopsy
  • OTC meds, PT
  • IV fluids, minor surgery

Minimal Risk:

  • 1 self limited minor Pb
  • Lab/XR/EKG
  • Rest/gargle
  • Bandage/Dressings