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E/M Documentation Auditors' InstructionsMedicare1. HistoryPart BRefer to data section (table below) in order to quantify. After referring to data, circle the entry farthest to the RIGHT in the table, whichbest describes the HPI, ROS and PFSH. If one column contains three circles, draw a line down that column to the bottom row toidentify the type of history. If no column contains three circles, the column containing a circle farthest to the LEFT, identifies the type ofhistory.After completing this table which classifies the history, circle the type of history within the appropriate grid in Section 5.HPI: Status of chronic conditions:Status ofStatus of 31 condition 2 conditions 3 conditions1-2 chronicHGSADMINISTRATORS DOCUMENTATION WORKSHEETchronicORconditionsconditionsHPI (history of present illness) elements:Location Severity Timing Modifying factorsBrief ExtendedQuality Duration Context Associated signs and symptoms (1-3)(4 or more)ROS (review of systems):Constitutional Ears,nose, GI Integumentary EndoNonePertinent to Extended **Complete(wt loss, etc) mouth, throat GU (skin, breast) Hem/lymphBeneficiary HIC #problemEyes Card/vasc Musculo Neuro All/immuno(2-9 systems)(1 system)Resp Psych All others negativePFSH (past medical, family, social history) areas:Past history ( the patient's past experiences with illnesses, operation, injuries and treatments)Complete*None PertinentFamily history (a review of medical events in the ...
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8985-1 F01/02
Medicare Part B
HGSADMINISTRATORS DOCUMENTATION WORKSHEET
Beneficiary HIC #
Provider Number
Date of Service
Procedure Code Reported
Check one:Agree Disagree
Documented Procedure Code Level
OVERPAYMENT AMOUNT $
Camp Hill, PA17089 www.hgsa.com
E/M Documentation Auditors' Instructions 1. History
Refer to data section (table below) in order to quantify.After referring to data, circle the entry farthest to theRIGHTin the table, which best describes the HPI, ROS and 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 theLEFT, 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. HPI: Statusof chronic conditions: Status of Status of 3 1 condition2 conditions3 conditions 1-2 chronic chronic ORconditions conditions HPI (history of present illness) elements: Location SeverityTiming Modifyingfactors Brief Extended Quality DurationContext Associatedsigns and symptomsor more)(1-3) (4 ROS (review of systems): Constitutional Ears,nose,GI IntegumentaryEndo None (wt loss, etc)mouth, throatGU (skin,breast) Hem/lymphPertinent toExtended **Complete problem Eyes Card/vascMusculo NeuroAll/immuno(2-9 systems) (1 system) Resp PsychAll others negative PFSH (past medical, family, social history) areas: Past history ( the patient's past experiences with illnesses, operation, injuries and treatments) Complete* NonePertinent Family history (a review of medical events in the patent's family, including diseases which may be (2 or 3 history areas) (1 history area) hereditary or place the patient at risk) Socal history (an age appropriate review of past and current activities) PROBLEMEXP.PROB.COMPRE-DETAILED FOCUSEDFOCUSEDHENSIVE *Complete PFSH:2 history areas:a) Established patients - office (outpatient) care, domiciliary care, home care; b) Emergency department; c) **10 or more systems, or some systems with Subsequent nursing facility care; d) Subsequent hospital care; and,statement "all others negative" e) Follow-up consultations. 3 history areas:a) New patients - office (outpatient) care, domiciliary care, home care;b) Initial consultations; c) Initial hospital care; d) Hospital observation; and, e) Comprehensive nursing facility assessments.
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.
Limited to affected body area or organ system (one body area or system related to problem)
Affected body area or organ system and other symptomatic or related organ system(s) (additional systems up to total of 7) Extended exam of affected area(s) and other symptomatic or related organ system(s) (additional systems up to total of 7 or more depth than above) General multi-system exam (8 or more systems) or complete exam of a single organ system (complete single exam not defined in these instructions)
Body areas: Head, including face Back, including spine Organ systems:
Chest, including breasts and axillae Genitalia, groin, buttocks
Constitutional Ears,nose, (e.g., vitals, gen app)mouth, throat Eyes Cardiovascular
Resp GI GU
Musculo Skin Neuro
Abdomen Neck Each extremity
- 1 -
Psych Hem/lymph/imm
PROBLEM FOCUSED EXAM
EXPANDED PROBLEM FOCUSED EXAM
DETAILED EXAM
COMPREHENSIVE EXAM
1 body area or system
Up to 7 systems
Up to 7 systems
8 or more systems
PROBLEMEXP.PROB.COMPRE-DETAILED FOCUSEDFOCUSEDHENSIVE
5. LE V E LO FS E R V I C E Beneficiary HIC #:Date of Service: 3. MedicalDecision Making Outpatient, Consults (OUTPATIENT, INPATIENT & CONFIRMATORY) and ER Number of Diagnoses or Treatment OptionsAmount and/or Complexity of Data Reviewed New Office / Consults / EREstablished Office Identify each problem or treatment option mentioned in the record. Enter the number in each of the categories in Column B in the tableFor each category of reviewed data identified, circle the number in the pointsRequires 3 components within shaded areaRequires 2 components within shaded area below. (Thereare maximum number in two categories.)Do notcolumn. Totalthe points. PF EPFD C C Minimal categorize the problem(s) if the encounter is dominated by HistoryproblemPF EPFD C counseling/coordinating of care, and duration of time is not specified. ER:PFER:EPFthat may Amount and/or Complexity of Data ReviewedER:EPFER:DER:C In that case, enter 3 in the total box. not PF EPFD C C Points Reviewed Data require Number of Diagnoses or Treatment Options ExaminationpresencePF EPFD C 1 Review and/or order of clinical lab tests ER:PFER:EPF AB X C= DER:EPFER:DER:C of 1 Review and/or order of tests in the radiology section of CPTphysician F NumberComplexityS SFL MH Problem(s) Status Points Result 1 of medicalSF LM H Review and/or order of tests in the medicine section of CPT Self-limited or minor 1ER:SFER:MER:H decision ER:LER:M Discussion of test results with performing physician (stable, improved or worsening) Max = 21 Average Time10 New (99201)20New (99202)30New (99203)45New (99204) 60New (99205) Decision to obtain old records and/or obtain history from Est. problem (to examiner); stable, improved1 115Outpt cons (99241)30Outpt cons (99242)40Outpt cons (99243)60Outpt cons (99244) 80Outpt cons (99245) (minutes) someone other than patientInpat cons (99255)Inpat cons (99251)Inpat cons (99252)Inpat cons (99253)Inpat cons (99254) 20 40 5580 1105 104015 25 Est. problem (to examiner); worsening2(Confirmatory Conf cons (99271)Conf cons (99272)Conf cons (99273)Conf cons (99274)Conf cons (99275) Review and summarization of old records and/or obtainingER (99285)ER (99283)ER (99284)ER (99281)ER (99282)(99211) (99212) (99213) (99214)(99215) consults & ER have New problem (to examiner); no additional3 history from someone other than patient and/or discussion of 2 no average time) workup planned case with another health care provider Max = 1 Level III III IV VI IIIII IV V New prob. (to examiner); add. workup planned4 Independent visualization of image, tracing or specimen itself TOTAL 2 (not simply review of report) Multiply the number in columns B & C and put the product in column D. TOTAL Enter a total for column D. INPATIENT Bring total toline Ain Final Result for Complexity (table below)Subsequent Inpatient/Follow-upInitial Hospital/Observation Bring total toline Cin Final Result for Complexity (table below) Consult Requires 3 components within shaded areaRequires 2 components within shaded area 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. HistoryD or CC CPF intervalD intervalEPF interval Risk of Complications and/or Morbidity or Mortality Enter the level of risk identified in Final Result for Complexity (table below). Level ofManagement OptionsDiagnostic Procedure(s) Presenting Problem(s) RiskExaminationOrdered SelectedEPF DD or CC C PF Laboratory tests requiring venipuncture • •One self-limited or minor problem,•Chest x-rays•Rest Complexity of medical e.g., cold, insect bite, tinea corporis •EKG/EEG•GarglesH SF/LM HSF/L M Minimal decision •Urinalysis• Elastic bandages Ultrasound, e.g., echoSuperficial dressings • • 30 Init hosp (99221)50 Init hosp (99222)70 Init hosp (99223)15 Subsequent(99231) 25Subsequent (99232) 35Subsequent (99233) Average time (minutes) • KOH prep Observ careObserv careObserv care10 FUcons (99261)20 FUcons (99262)30 FUcons (99263) (Observation care has no average time) (99218) (99219)(99220) Level •Physiologic tests not under stress, e.g.,pulmonaryIII I III II •Two or more self-limited or minor problemsIII function tests•Over-the-counter drugs •One stable chronic illness, e.g., well controlled •Non-cardiovascular imaging studies with contrast,•Minor surgery with no identified risk factors hypertension or non-insulin dependent diabetes, e.g., barium enema Physical therapy • cataract, BPH Superficial needle biopsies Low• •Occupational therapy • Acute uncomplicated illness or injury, e.g., cystitis, allergic IV fluids without additivesNURSING •Clincal laboratory tests requiring arterial puncture Annual Assessment/Admission • rhinitis, simple sprain •Skin biopsies Subsequent Nursing Facility FACILITYNew PlanOld Plan ReviewAdmission Requires 3 components within shaded areaRequires 2 components within shaded area •One or more chronic illnesses with mild exacerbation, •Minor surgery with identified risk factors Physiologic tests under stress, e.g., cardiac stress test, • progression, or side effects of treatment •Elective major surgery (open, percutaneous or fetal contraction stress test •endoscopic) with no identified risk factorsHistoryD intervalD intervalinterval EPFC PFintervalinterval D Two or more stable chronic illnesses Diagnostic endoscopies with no identified risk factors • Undiagnosed new problem with uncertain prognosis, •Deep needle or incisional biopsy•Prescription drug management • Moderatee.g., lump in breast•Cardiovascular imaging studies with contrast and no•Therapeutic nuclear medicine Acute illness with systemic symptoms, e.g., •identified risk factors, e.g., arteriogram cardiac cathIV fluids with addititives • ExaminationC CEPF DC PF • •Closed treatment of fracture or dislocation without pyelonephritis, pneumonitis, colitisObtain fluid from body cavity, e.g., lumbar puncture, Acute complicated injury, e.g., head injury with brief lossthoracentesis, culdocentesis •manipulation of consciousnessComplexity of medical SF/L Mto HM to HSF/L MM to H decision One or more chronic illnesses with severe exacerbation, •Elective major surgery (open, percutaneous or • progression, or side effects of treatment endoscopic with identified risk factors) Average time (minutes) Acute or chronic illnesses or injuries that may pose a threat toCardiovascular imaging studies with contrast with • • Emergency major surgery (open, percutaneous or • life or bodily function, e.g., multiple trauma, acute MI,identified risk factors30 40 50 15 25 35 (Confirmatory consults & ER have no average(99301) (99302) (99303) (99311) (99312) (99313) endoscopic) pulmonary embolus, severe respiratory distress, progressivetime) Cardiac electrophysiological tests High• •Parenteral controlled substances •Diagnostic endoscopies with identified risk factors severe rheumatoid arthritis, psychiatric illness with potential • Drug therapy requiring intensive monitoring for toxicity threat to self or others, peritonitis, acute renal failureLevel IIIII IIII III Discography • Decision not to resuscitate or to de-escalate care • An abrupt change in neurologic status, e.g., seizure, TIA, • because of poor prognosis weakness or sensory loss DOMICILIARY (Rest Home, Custodial Care) and Home Care Final Result for Complexity New Established 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 2nd circle from the left. Requires 3 components within shaded areaRequires 2 components within shaded area After completing this table, which classifies complexity, circle the type of decision 4. Time making within the appropriate grid in Section 5. HistoryC PFinterval EPFinterval Dinterval CPF EPF D C Final Result for Complexity If the physician documents total timeandsuggests that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: 2 3 ≤ 1≥ 4 Number diagnoses orprognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk reduction AMinimal Limited MultipleExaminationCEPF DC PFPF EPF D C Extensive treatment options or discussion with another health care provider. M H Complexity ofSF/L SF/LM H B Face-to-face in outpatient setting Highest RiskMinimal LowModerate HighTime:HM H Does documentation reveal total time?Unit/floor in inpatient settingYes No medical decision SF LM SFL M Amount and complexity≤ 1Does documentation describe the content of counseling or coordinating care? C2 3 ≥ 4Yes NoNo average timeDomiciliary (99321)Domiciliary (99322)Domiciliary (99323)Domiciliary (99331)Domiciliary (99332)Domiciliary (99333) of dataMinimal Limited MultipleHome careHome careHome care ExtensiveHome care (99349)Home care (99348)Home care (99347)Home care (99343)Home care (99342)Home care (99341) established or low (99344)(99345) (99350) Does documentation reveal that more than half of the time was counseling or Yes No coordinating care? STRAIGHT- LOW MODERATEHIGH Level III IIIIV VI IIIII IV Type of decision making FORWARD COMPLEX. COMPLEX.COMPLEX. If all answers are "yes", select level based on time. PF = Problem focusedEPF = Expanded problem focusedD = DetailedC = ComprehensiveSF = StraightforwardL = LowM = ModerateH = High 8985-2 E11/03- 2 -- 3 -
