T I M E



|Chief Complaint: Program: |PROBLEM-FOCUSE|EXP PROB |DETAILED |COMPRE-HENSIVE |

| |D |FOCUSED | | |

|HISTOR|Circle appropriate entry furthest to right, under level of service |

|Y | |

| |HPI (history of present illness) elements: |

| |Location Severity Timing Modifying factors |

| |Quality Duration Context Associated signs and symptoms |

| |Organ|System r/t problem |

| |Syste| |

| |ms | |

| |(1995| |

| |Guide| |

| |lines| |

| |): | |

| |Const| |

| |ituti| |

| |onal | |

| |(e.g.| |

| |, | |

| |vital| |

| |signs| |

| |, | |

| |gener| |

| |al | |

| |appea| |

| |rance| |

| |) | |

| |Eyes | |

| |Ears,| |

| |nose,| |

| |mouth| |

| |, | |

| |throa| |

| |t | |

| |Cardi| |

| |ovasc| |

| |ular | |

| |Respi| |

| |rator| |

| |y | |

| |Gastr| |

| |ointe| |

| |stina| |

| |l | |

| |Genit| |

| |ourin| |

| |ary | |

| |Muscu| |

| |loske| |

| |letal| |

| |Skin | |

| |Neuro| |

| |logic| |

| |Psych| |

| |iatri| |

| |c | |

| |Hemat| |

| |ologi| |

| |c/Lym| |

| |phati| |

| |c/Imm| |

| |unolo| |

| |gic | |

| |Problems to Exam Physician |Number X Points = Result |

| |Self-limited or minor (stable, improved or | |1 |Max = 2 |

| |worsening) | | | |

| |Est. problem (to examiner); stable, improved | |1 | |

| |Est. problem (to examiner); worsening | |2 | |

| |New problem (to examiner); no additional | |3 |Max = 3 |

| |workup planned | | | |

| |New prob. (to examiner); add. workup planned | |4 | |

| |Bring total to line A in Final Result for |TOTAL | |

| |Complex. | | |

| |C |Amount and/or Complexity of Data to be Reviewed |

| |Data to be Reviewed |Points |

| |Review and/or order of clinical lab tests |1 |

| |Review and/or order of tests in the radiology section of CPT |1 |

| |Review and/or order of tests in the medicine section of CPT |1 |

| |Discussion of test results with performing physician |1 |

| |Decision to obtain old records and/or obtain history from |1 |

| |someone other than patient | |

| |Review and summarization of old records and/or obtaining history|2 |

| |from someone other than patient and/or discussion of case with | |

| |another health care provider | |

| |Independent visualization of image, tracing, or specimen itself |2 |

| |(not simply review of report) | |

| |Bring total to line C in Final Result for Complexity TOTAL | |

| |Final Result for Complexity | |

| |A |

|Level of|Presenting Problem(s) |Diagnostic Procedure(s)|Management Options |

|Risk | |Ordered |Selected |

|M |One self-limited or minor |Laboratory tests |Rest |

|I |problem, e.g., cold, insect |requiring venipuncture |Gargles |

|N |bite, tinea corporis |Chest x-rays |Elastic bandages |

|I | |EKG/EEG |Superficial dressings |

|M | |Urinalysis | |

|A | |Ultrasound, e.g., echo | |

|L | |KOH prep | |

|L |Two or more self-limited or |Physiologic tests not |Over-the-counter drugs|

|O |minor problems |under stress, e.g.pulm.|Minor surgery with no |

|W |One stable chronic illness, |function tests |identified risk |

| |e.g., well controlled |Non-cardiovascular |factors |

| |hypertension, non-insulin |imaging studies with |Physical therapy |

| |dependent diabetes, cataract,|contras, e.g., barium |Occupational therapy |

| | |enema |IV fluids without |

| |BPH |Superficial needle |additives |

| |Acute uncomplicated illness |biopsies | |

| |or injury, e.g., cystitis, |Clinical laboratory | |

| |allergic rhinitis, simple |tests requiring | |

| |sprain |arterial puncture | |

| | |Skin biopsies | |

|M |One or more chronic illnesses|Physiologic tests under|Minor surgery with |

|O |with mild exacerbation, |stress, e.g., cardiac |identified risk |

|D |progress, or side effects of |stress test, fetal |factors |

|E |treatment |contraction stress test|Elective major surgery|

|R |Two or more stable chronic |Diagnostic endoscopies |(open, percutaneous or|

|A |illnesses |with no identified risk|endoscopic) with no |

|T |Undiagnosed new problem with |factors |identified risk |

|E |uncertain prognosis, e.g., |Deep needle or |factors |

| |lump in breast |incisional biopsy |Prescription drug |

| |Acute illness with systemic | |management |

| |symptoms, e.g., | |IV fluids with |

| |pyelonephritis, pneumonitis, | |additives |

| |colitis | |Closed treatment of |

| |Acute complicated injury, | |fracture or |

| |e.g.head injury with brief | |dislocation without |

| |loss of consciousness | |manipulation |

|H |One or more chronic illnesses|Cardiovascular imaging |Elective major surgery|

|I |with severe exacerbation, |studies with contrast |(open, percutaneous or|

|G |progression, or side effects |with identified risk |endoscopic) identified|

|H |of tx |factors |risk factors |

| |Acute or chronic illnesses or|Diagnostic endoscopies |Emergency major |

| |injuries that may pose a |with identified risk |surgery |

| |threat to life or bodily |factors |Parenteral controlled |

| |function, e.g., multiple |Discography |substances |

| |trauma, acute MI, pulmonary | |Drug therapy requiring|

| |embolus, severe respiratory | |intensive monitoring |

| |distress, progressive severe | |for toxicity |

| |rheumatoid arthritis, | | |

| |psychiatric illness with | | |

| |potential threat to self or | | |

| |others, peritonitis, acute | | |

| |renal failure | | |

Bring result to Line B in Final Result for Complexity

|T I M |If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter, | |

|E |time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of | |

| |treatment, instructions, compliance, risk reduction or discussion with another health care provider. | |

| |Does documentation reveal total time (Face to Face time with a patient.) | Yes | No |If all answers are “yes”, may |

| | | | |select level based on time. |

| |Does documentation describe the content of counseling or coordinating care | Yes | No | |

| |Does documentation reveal that more than half of time was counseling or coordinating care | Yes | No | |

|Outpat| |New / Consults |Established |

|ient | | | |

| | |Requires 3 components. Overall level is determined by the column marked furthest to the left.|Requires 2 components in one column |

|History |PF |EPF |D | |C | |PF |EPF |D |C | | |Examination |PF |EPF |D | |C | |PF |EPF |D |C | | |Complexity of medical decision | |SF |L |M |H | |SF |L |M |H | | |Average Time (minutes) |

10 New (99201)

|

20 New (99202)

|

30 New (99203)

|

45 New (99204)

|

60 New (99205)

| 5

(99211) |10

(99212) |15

(99213) |25

(99214) |40

(99215) | | |Level |I |II |III |IV |V |I |II |III |IV |V | |

Review Tool #:_____________Patient ID:_________________________ DOS:____________ Billed CPT Code:_________________ Reviewed CPT Code:__________________

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4+ elements or status of 3+ chronic or inactive conditions

1-3 elements

CPT Clinical Record Review Tool

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