Name/ID Number:________________________



1995 New Patient/Office Consultations 3 of 3

Pt. ID:_______________________ Pt. Name:______________________________ Visit Date:_________________

MD:_________________________ Provider E&M Code______________ Reviewer E&M Code______________

Pt. Status: ____New ____Established Service Type: ___Office ___ Consult ____ Other_____________________

Chief Complaint Documented ____Yes ____No

History 99201=99241, 99202=22242, 99203=99243, 99204=99244, 99205=99245

|Circle Lowest Level Obtained |99201 |99202 |99203 |99204 |99205 |

|HPI |1-3 |4 |4 |

|Location, Quality, Severity, Duration, Timing, Context, Mod. Factors, Assoc. S&S | | | |

|ROS |0 |1 |2-9 |10 |

|Constitutional Eyes ENT CV Resp GI GU MS Skin/Breast Neuro Psych | | | | |

|Endo Hem/lym All/lmm “All others Negative” | | | | |

|PMFSHx |0 |1 |3 |

|Past Medical Past Family Past Social |

|*Current Meds *Health status or cause of death of parents, siblings, & children *Living Arrangements *Current Employment |

|*Prior Ill/Injuries *Disease related to chief complaint, HPI, or ROS *Marital status |

|*Other |

|*Dietary Status *Hereditary or high risk diseases *Sexual Hx |

|*Oper. & Hospital. *Occupational Hx |

|*Allergies *Use of Drugs, |

|Alcohol, or Tobacco |

|*All approp. Immun. *Extent of Education |

Examination(95) 99201=99241, 99202=99242, 99203=99243, 99204=99244,99205=99245

|Circle Level |99201 |99202 |99203 |99204 |99205 |

|(Body Areas) – Head/face - Neck -Chest/breast/Axilla - Abd |1 |2-4 |5-7 |8+ |

|- Back/Spine - Genitalia/groin/butt - Each Extremity (1,2,3,4) | | | | |

| | | | | |

|(Systems) – Constitutional - Eyes - ENT - CV - Respiratory - GI | | | | |

|- GU - MS - Skin - Neuro - Psych - Hem/lymp/lmm | | | | |

|-There was detail in the exam. of the body area(s) or organ system(s) relating to the presenting problem | | | | |

|-There was a “Complete Examination” of a single organ system (Comprehensive) | | | | |

Medical Decision Making 99201=99241, 99202=99242, 99203=99243, 99204=99244, 99205=99245

|Circle Level - 2 out of 3 |99201 |99202 |99203 |99204 |99205 |

|Diagnoses/Management Options |1 |1 |2 |3 |4 |

|1 Minor = 1 | | | | | |

|Estab. Dx improved, well controlled, resolving or resolved = 1 or 2 | | | | | |

|1 or 2+ self limited or minor problem(s) = 2 pts. Highest | | | | | |

|Estab. Dx inadequately controlled, worsening, or failing to change as expected: | | | | | |

|1= 2pts; 2+= 4 pts. | | | | | |

|1 New problem with no additional work up planned = 3 | | | | | |

|1 New problem with additional work up planned = 4 | | | | | |

|Amount/Complexity of Data |0-1 |0-1 |2 |3 |4 |

|Review and/or order of lab(s) = 1 or X-ray(s) = 1 or tests from 70-90000 sec = 1 | | | | | |

|Discussion of test with performing MD = 1 | | | | | |

|Decision to obtain old records and/or history from someone other than patient = 1 | | | | | |

|Review and summarize old records and/or obtain history from someone other than patient and/or discussion | | | | | |

|of case with another health care provider = 2 | | | | | |

|Indep. visualization of image, tracing, or specimen itself = 2 | | | | | |

|Risk Level |Min. |Min. |Low |Mod. |High |

Choose level of service for which all three components are met or exceeded

TEACHING PHYSICIAN DOCUMENTATION GUIDELINES FOR E&M SERVICES – MODIFIER GC

Has the Teaching Physician: Provided documentation of participation in the service? Yes No

Documented the history of present illness? Yes No

Resident:________________ Documented that she/he has seen and/or examined the patient? Yes No

Documented a reference to the resident’s note? Yes No

Documented a summary comment about the history? Yes No

Documented a summary comment about the physical exam? Yes No

Documented a summary comment about the medical decision making? Yes No

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