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Name/Case:???DOB:? ?DOS:?Chief Complaint:????Rendering provider:???New patient OR?Established PatientHistory Level (HX) - Check each system reviewed with patient verbally. When auditing these elements, each element should only be considered once to satisfy the requirements for either: HPI, ROS or PSFH.Step 1. History of Present Illness (HPI)? Check if 3 or more chronic conditions were reviewed. If so, skip 1 (automatically Extended HPI). If not, complete 1 (HPI).1. Check each element reviewed with patient: ????????LocationQualitySeverityDurationTimingContextModifying FactorsAssociated Signs and Symptoms(Where problem is located)(Sharp, dull, stabbing, etc.)(Scale of 1-10, etc.)(How long has problem occurred)(How long it lasts, after meals, etc.)(When walking, etc.)(Feels better after applying ice, medication helps, etc.)(Swelling, redness, fatigue, etc.)2. Check level of HPI:Levels? N/A? Brief? ExtendedDescriptionNone are checked1-3 elements of HPI4 or more elements A. Step 2. Review of System (ROS)1. Check all systems reviewed. If none were reviewed, mark N/A in final history level calculation below.???????ConstitutionalEyesEars, Nose, Mouth, ThroatCardiovascularRespiratoryGastrointestinalMusculoskeletal????????IntegumentaryGenitourinaryNeurologicalPsychiatricEndocrineHematologic/LymphaticAllergic/ImmunologicAll Others Negative2. Check level of ROS:Levels? N/A? Pertinent? Extended? CompleteDescriptionNone are checked1-2 ROS related to HPI3-9 ROS related to HPI and a limited number of additional systems10 or more ROS (documentation of “all others systems are negative” is acceptable)A. Step 3. Past Medical Family and Social History (PFSH)1. Check all areas reviewed:PastFamilySocial? Reviewed (Past experiences with illness, operations, & treatments)?Reviewed (Medical events in pt’s. family including diseases)?Reviewed (Age appropriate review of past and current activities, such as smoking, drug and alcohol use)2. Determine if new or established patient, then check level:Levels? Pertinent? Complete New Patient At least 1 area reviewed All 3 areas reviewed Established PatientAt least 1 area reviewed 2-3 areas reviewed Final History Level (HX) CalculationTo obtain History Level (HX), use results from Steps 1 (HPI), 2 (ROS) and 3 (PFSH) above. If HPI is extended, check both listed. The final HX level is determined by whichever row closest to 1 has a check. RowStep 1. HPIStep 2. ROSStep 3. PFSHResult for A. History Level (HX)1?N/A?N/A?N/A??Problem Focused2?Brief?Pertinent??N/A??Expanded Problem Focused3?Extended?Extended??Pertinent??Detailed4?Extended??Complete??Complete??ComprehensiveB. Examination Level – Select each body area or organ system examined during the visit Step 1: Body Area (BA)Check each of the body areas examined:??????Extremities/LimbsHead (Include Face)NeckChest (Include Breast/ Axillae)Abdomen Genital/ Groin/ ButtocksBack (Spine)????Upper LeftUpper RightLower LeftLower RightStep 2: Organ System (OS)Check each organ system examined:??????Constitutional EyesEar, Nose, Mouth and ThroatCardiovascularRespiratoryGastrointestinal ??????GenitourinaryMusculoskeletal SkinNeurologicPsychiatricHematologic/Lymphatic/ImmunologicFinal Examination Level Calculation (Based on 1995 Guidelines)Calculate the examination level using results from Steps 1 Body Area (BA) and 2 Organ System (OS) above.Result for B. Examination Level????????Problem Focused 1 BA or OSExpanded Problem Focused2 - 7 BA and/or OSDetailed2 - 7 BA and/or OSComprehensive8 or more OSLimited exam of affected BA or OSLimited exam of affected BA or OS and other related OSExpanded exam including more than one element of the affected BA or OS and other related OSA general multisystem exam (Note: does not include BA)C. Complexity of Medical Decision MakingStep 1: Number of Diagnosis or Management OptionsFor each of the elements below, determine the corresponding number of diagnosis or management options supported by the medical record. Calculate results by multiplying the number and the points. Then calculate the total points by adding results for each element.ElementNumber XPoints =ResultsSelf-limited or minor (stable, improved or worsening) (e.g. bug bite with no treatment advice given)Max#21?Establish problem (to examiner); stable or improved?1?Establish problem (to examiner); worsening?2?New problem (to examiner); no additional workup plannedMax#13?New problem (to examiner); additional workup planned?4?Total?Step 2: Amount and/or Complexity of Data ReviewedFor each category below, write in the number of points using the Points Possible column if apparent in the medical record. Then calculate the total points by summing the points for each category.Category??????Points PossiblePointsReview and/or order of clinical lab tests1?Review and/or order of tests in the radiology section of CPT1?Review and/or order of tests in the medicine section of CPT1?Discussion of test results with performing physician1?Decision to obtain old records and/or obtain history from someone other than patient1?Review and summarization of old records and/or obtaining history from someone other than patient and/or discussion of case with another health care provider2?Independent visualization of image, tracing or specimen itself (not simply review of report)2?Total?Step 3: Risk of Complications, Morbidity, and/or Mortality Check all that apply. The highest risk level in any category determines the overall risk.Risk LevelPresenting Problem(s)Diagnostic Procedure(s) OrderedManagement Options SelectedMinimalOne self-limited or minor problem (e.g. cold, insect bite, tinea corporis) ?Laboratory tests requiring venipuncture Chest x-raysEKG/EEG UrinalysisUltrasound (echo) KOH prep ?Rest Gargles Elastic bandages Superficial dressings ? LowTwo or more self-limited or minor problems One stable chronic illness (well controlled hypertension, non-insulin dependent diabetes, cataract, BPH) Acute uncomplicated illness or injury (cystitis, allergic rhinitis, simple sprain) ?Physiologic tests not under stress (pulmonary function tests) Non-cardiovascular imaging studies with contrast (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 therapyIV fluid without additives ?ModerateOne or more chronic illnesses with mild exacerbation, progression, or side effects of treatment Two or more stable chronic illnessesUndiagnosed new problem with uncertain prognosis (lump in breast) Acute illness with systemic symptoms (pyelonephritis, pneumonitis, colitis) Acute complicated injury (head injury with brief loss of consciousness) ?Physiologic tests under stress (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 (arteriogram, cardiac catheterization)Obtain fluid from body cavity (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 medicineIV fluids with additives Closed treatment of fracture or dislocation without manipulation ?HighOne or more chronic illnesses with severe exacerbation, progression, or side effects of treatmentAcute or chronic illnesses or injuries that may pose a threat to life or bodily function (multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self/others, peritonitis, acute renal failure) An abrupt change in neurological status (seizure, 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 factorsEmergency major surgery (open, percutaneous or endoscopic) Parenteral controlled substanceDrug therapy requiring intensive monitoring for toxicity Decision not to resuscitate or to de-escalate care because of poor prognosis ?Final Complexity of Medical Decision Making Level CalculationUse results from steps 1, 2, and 3 to check one box in rows A-C. Select the final complexity based on the column with 2 or more selections or select the column with one selection in the least complex column.ANumber of Diagnosis or Management Options (total from Step 1)????≤1Minimal2Limited3Multiple≥4ExtensiveBAmount and/or Complexity of Data Reviewed(total from Step 2)????≤1Minimal2Limited3Multiple≥4ExtensiveCRisk of Complications, Morbidity and/or Mortality(total from Step 3)????MinimalLowModerateHigh????Result for C. Complexity of Medical Decision Making LevelStraight-ForwardLow ComplexityModerate ComplexityHigh ComplexityD. Time SpentIf appointment time for counseling or coordinating care is indicated on the medical record, time may help determine level of service. If not, skip this section. If so, check all that apply. If all 3 are not checked, do not factor into level of service selection (category E).??Does documentation reveal total time? (Time spent face to face with the patient)??????Does documentation describe the content of counseling or coordinating care?????Does documentation reveal that more than half of the time was counseling or coordinating care?E. Level of Service- Select which table to fill out based on the patient’s status (new vs. established)Using the information from the sections above, check the results for each key component.? Only include time if all 3 boxes are checked.? For new patients, all of the key components must meet or exceed the level of service. For established patients, only two key components must meet the level of service.? CategoryNew PatientA. History?????Problem FocusedExpanded Problem FocusedDetailedComprehensiveComprehensiveB. Examination?????Problem FocusedExpanded Problem FocusedDetailedComprehensiveComprehensiveC. Complexity of Medical Decision Making?????Straight-forwardStraight-forwardLowModerate HighD. Time?????1020304560E. Level of Service?????9920199202992039920499205CategoryEstablished PatientA. History?????*Problem FocusedExpanded Problem FocusedDetailedComprehensiveB. Examination?????*Problem FocusedExpanded Problem FocusedDetailedComprehensiveC. Complexity of Medical Decision Making?????*Straight-forwardLowModerateHighD. Time?????510152540E. Level of Service?????9921199212992139921499215*Minimal problem that does not require presence of a physician ................
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