Chief Complaint:______

EXPANDED HISTORY – 1st KEY Component PROBLEM PROBLEM DETAILED COMPREHENSIVE FOCUSED (MUST meet or exceed 3 / 3 history areas for a level of service) → FOCUSED HPI (History of Present Illness) elements: Brief Brief Extended Extended □ Location □ Severity □ Timing □ Modifying Factors 1-3 elements 1-3 elements ≥ 4 elements or status 3 + ≥ 4 elements or status 3 +

□ Quality □ Duration □ Context □ Associated Signs & Symptoms chronic/inactive conditions chronic or inactive conditions ROS (Review Of Systems): Pertinent to Extended Complete □ Constitutional (wt. loss, etc.) □ Ears, nose, mouth, throat □ Eyes □ GI problem ≥ 10 systems OR None □ Integ. (skin, breast) □ Endo □ Hem/Lymph □ GU □ All/Imm 2-9 systems 10 + systems with statement 1 system “all others negative” □ Card/Vas □ Resp □ Musc □ Neuro □ Psych □ All others negative PFSH (Past Medical, Family, Social History) areas:

□ Past history (the patient’s past experiences with illnesses, operations, Complete* Pertinent injuries and treatments) None None Family history (a review of medical events in a patient’s family, 2 OR 3 □ 1 history area including diseases which may be hereditary or place the patient at risk) history areas □ Social history (an age appropriate review of past and current activities) If physician is unable to obtain history, the record should describe circumstances which identify the reason “why” it can NOT be obtained. NO PFSH is required for: a) subsequent hospital care; b) Subsequent nursing facility care; c) Est. pts – Domiciliary, rest home & home *Complete PFSH: 2 history areas: a) Established patient office (outpatient) care; domiciliary care; home care; b) Emergency department 3 history areas: a) New pt. office (outpatient) care; domiciliary care; home care; b) Consults; c) Initial hosp care; d) Hosp Observ. e) Comprehensive Nurse Facility Assessments ← EXAMINATION → General Multi-system Exam:: 2nd KEY Component Single Organ System Exams: 1-5 elements identified by • PROBLEM FOCUSED 1-5 elements identified by • ≥ 6 elements identified by • EXPANDED PROBLEM FOCUSED ≥ 6 elements identified by • ≥ 2 elements identified by • from 6 areas/systems OR ≥ 12 elements identified by • EXCEPT……………….. DETAILED ≥ 12 elements identified by • from at least 2 + areas/systems Eye and Psychiatric exams ≥ 9 elements identified by • Perform all elements identified by • document all elements ≥ 2 elements identified by • from 9 areas/systems COMPREHENSIVE in shaded boxes; document ≥ 1 element in unshaded boxes C) Risk of Complications and/or Morbidity/Mortality (Bring result to Line C in Final Result of MDM)

rd Level Presenting Diagnostic Management Medical Decision Making - 3 KEY Component of Risk Problem(s) Procedure(s) Ordered Options Selected A) Number of Diagnoses or Treatment Options •One self-limited or minor •Laboratory test requiring • Rest problem, e.g. cold, insect venipuncture • Gargles Number of Problems to Examiner Number X Points=Result bite, tinea corporis • Chest x-rays • Elastic bandages Self-limited or minor • EKG/EEG • Superficial 1 (stable, improved or worsening) Max=2 • Urinalysis dressings Established problem (to examiner); • Ultrasound, e.g. echo

1 MINIMAL stable, improved • KOH prep Established problem (to examiner); worsening 2 • Two or more self-limited • Physiologic tests not under • Over-the-counter drugs New problem (to examiner); or minor problems stress e.g. pulm.. function tests • Minor surgery 3 NO additional workup planned Max = 3 • One stable chronic illness,e.g. • Non-cardiovascular imaging with no identified well controlled hypertension, studies with contrast, e.g. risk factors New problem (to examiner); 4 non-insulin dependent barium enema • Physical therapy additional workup planned LOW diabetes, cataract, BPH • Superficial needle biopsies • Occupational therapy • Acute uncomplicated illness • Clinical laboratory tests • IV fluids without Bring total to Line A in Final Result for MDM TOTAL =______or injury, e.g. cystitis, allergic requiring arterial puncture additives rhinitis, simple sprain • Skin biopsies B) Amount and/or Complexity of Data to be Reviewed • One or more chronic illnesses •Physiologic tests under stress • Minor surgery with with mild exacerbation, e.g. cardiac stress test, fetal identified risk factors Data to Be Reviewed and/or Ordered Points progression, or side effects contraction stress test •Elective major surgery Review and/or order of clinical lab tests 1 of treatment • Diagnostic endoscopies with (open, percutaneous, Review and/or order of tests in the radiology section of CP 1 • 2 or > stable chronic illnesses no identified risk factors endoscopic) with no Review and/or order of tests in the medicine section of CP 1 •Undiagnosed new prob. with • Deep needle or incisional identified risk factor Discussion of test results with performing physician 1 uncertain prog. e.g. breast biopsy •Prescription drug lump • Cardiovascular. imaging studi management Decision to obtain old records and/or obtain history from 1 • Acute illness with systemic with contrast and no identified •Therapeutic nuclear someone other than patient symptoms e.g. pneumonitis risk factors, e.g. arteriogram, medicine. Review and summarization of old records and/or obtainin pyelonephritis, colitis cardiac cath. •IV fluids with additives history from someone other than patient and/or discussion 2 • Acute complicated injury • Obtain fluid from body cavity •Closed treatment of of case with another health care provider e.g. head injury with brief e.g. lumbar puncture, fracture or dislocation Independent visualization of image, tracing or specimen MODERATE 2 loss of consciousness thoracentesis, culdocentesis without manipulation itself (not simply review of report) • One or more chronic illnesses • Cardiovascular imaging • Elective major surgery with severe exacerbation, studies with contrast with (open, percutaneous, or Bring total to Line B in Final Result of MDM TOTAL =______progression, or side effects of tx identified risk factors endoscopic) with •Acute or chronic illnesses or • Cardiac electrophysiological identified risk factors FINAL RESULT OF MEDICAL DECISION MAKING injuries that may pose a threat test • Emergency major Number diagnosis to life or bodily function , e.g. • Diagnostic endoscopies with surgery (open, percutan. ≤ 1 2 3 ≥ 4 A or management multiple trauma, acute MI, identified risk factors or endoscopic) Minimal Limited Multiple Extensive options pulmonary embolus, severe • Discography •Parenteral controlled Amount and ≤ 1 respiratory distress, progressive substances 2 3 ≥ 4 severe rheumatoid arthritis, • Drug therapy requiring B Complexity of Minimal Limited Moderate Extensive psychiatric illness with intensive monitoring for Data or low potential threat to others, acute toxicity C Highest Risk Minimal Low Moderate High renal failure, peritonitis • Decision not to Type of Decision Straight- Low Moderate High • An abrupt change in resuscitate or to de- Making Forward Complex Complex. Complex. neurologic status, e.g. seizure, escalate care because of (MUST meet or exceed 2/3 MDM areas for a level of service) HIGH TIA, weakness or sensory loss poor prognosis

Outpatient, Consultations (Out-pt., In-pt.), and ER

New Patients– Consultations – ER Patients Established Patients Requires 3 out of 3 KEY components Requires 2 out of 3 KEY components ______History PF EPF D C C PF EPF D C ER: EPF ER: D ______Examination PF EPF D C C PF EPF D C ER: EPF ER: D ______MDM SF SF L M H SF L M H ER: L ER:M ______New 99201 99202 99203 99204 99205 Out-pt. consults 99241 99242 99243 99244 99245 In-pt. consults 99251 99252 99253 99254 99255 99211 99212 99213 99214 99215 Emergency Room 99281 99282 99283 99284 99285

E/M LEVEL: 1 2 3 4 5 1 2 3 4 5

Hospital In-patient

Initial Hospital (H & P) or Observation Subsequent Hospital Inpatient Requires 3 out of 3 KEY components Requires 2 out of 3 KEY components ______History D or C C C PF - Interval EPF - Interval D - Interval ______Examination D or C C C PF EPF D ______

MDM SF/L M H SF/L M H ______

Initial hospital 99221 99222 99223 Subsequent → 99231 99232 99233 Observation care 99218 99219 99220

E/M LEVEL: 1 2 3 1 2 3

Nursing Facility Annual Assessment/Admission Subsequent Nursing Facility Requires 3 out of 3 KEY components Requires 2 out of 3 KEY components

History D – Interval C - Interval C PF - Interval EPF - Interval D – Interval C ______Examination C C C PF EPF D C ______MDM SF/L M H SF/L M M H ______

Initial hospital 99304 99305 99306 99307 99308 99309 99310

E/M LEVEL: 1 2 3 1 2 3 4

Domiciliary and Home Care

New Patient Established Patient Requires 3 out of 3 KEY components Requires 2 out of 3 KEY components

History PF EPF D C C PF EPF D C ______Examination PF EPF D C C PF EPF D C ______MDM SF L M M H SF L M M toH ______

Domiciliary 99324 99325 99326 99327 99238 99334 99335 99336 99337 Home Care 99341 99342 99343 99344 99345 99347 99348 99349 99350

E/M LEVEL: 1 2 3 4 5 1 2 3 4

History and Examinations: PF = Problem Focused EPF = Expanded Problem Focused D = Detailed C = Comprehensive Medical Decision Making (MDM): SF = Straightforward L = Low M = Moderate H = High