DOCUMENTATION OF HISTORY
|DOCUMENTATION OF HISTORY |EXAMINATION |GENERAL PRINCIPLES |
|HISTORY OF PRESENT ILLNESS (HPI) |Organ Systems |LEGIBLE DOCUMENTATION SHOULD INCLUDE: |
|The HPI is a chronological description of the development |Constitutional (e.g. vital signs, general appearance) |Date and legible identity |
|of the patient’s present illness from the first sign and/or|Eyes |Reason for encounter (chief complaint) & history of |
|symptom or from the previous encounter to the present. It |Ears, nose, mouth, and throat |present illness (HPI) |
|includes the following elements: |Cardiovascular |Physical exam findings & test results |
|Location |Respiratory |Assessment, impression, or diagnosis |
|Quality |Gastrointestinal |Plan for care (test ordered, meds, procedures, Etc.) |
|Severity |Genitourinary | |
|Timing |Musculoskeletal |MODIFIERS: |
|Duration |Skin |24 Unrelated E&M service by same physician during postop |
|Context |Neurological |period |
|Modifying factors |Psychiatric |25 Separate E&M service by same physician on same day as |
|Associated signs and symptoms |Hematologic/lymphatic/immunologic |procedure |
| | |57 An E&M service resulted in decision to perform surgery|
|1-3 elements – Brief History |DOCUMENTATION OF MEDICAL DECISION MAKING (MDM) | |
|4 or more – Extended History |Number of diagnoses or management options |REPORT VISITS |
| |Amount and/or complexity of data to be reviewed |TIME: If counseling and/or coordination of care exceeds |
| |Risk or complications and/or morbidity or motility |50% of the face-to-face physician/patient encounter, the |
|REVIEW OF SYSTEMS (ROS) |Type of decision making |physician may bill an appropriate level of service based |
|Constitutional symptoms (e.g. fever, weight loss) | |on the time spent. Documentation must include the total |
|Eyes |Minimal |encounter time AND the note must indicate more than 50% |
|Ears, nose, mouth, throat |Minimal or none |of the time was spent counseling regarding test results, |
|Cardiovascular |Minimal |treatment options, etc. (eg: 60/40) |
|Respiratory |Straightforward | |
|Gastrointestinal | | |
|Genitourinary |Limited | |
|Musculoskeletal |Limited | |
|Integumentary |Low | |
|Neurologic |Low Complexity | |
|Psychiatric | | |
|Endocrine |Multiple | |
|Hematologic/lymphatic |Moderate | |
|Allergic/immunologic |Moderate | |
| |Moderate Complexity | |
|Problem pertinent= 1 system | | |
|Extended= 2-9 systems |Extensive | |
|Complete = 10 or more systems |Extensive | |
| |High | |
| |High Complexity | |
|PAST, FAMILY and/or SOCIAL HISTORY (PFSH) | | |
|Pertinent = Review of the History area directly related to | | |
|the problem |Problem Focused – exam of affected body or organ system (1) | |
|Complete = Review 2 or all 3 history areas. |Expanded Problem Focused – exam of affected body area or organ system plus | |
| |other symptomatic or related organ system (2-7) | |
| |Detailed – extended exam (2-7) | |
| |Comprehensive – general multi-system examination (8 or more organ systems) or | |
| |complete examination of a single organ system (specialty exam) | |
| | | |
TABLE OF E & M CODE REQUIREMENTS
| |NEW PATIENT |ESTABLISHED PATIENT |
|E & M CODES |99201 |99202 |
History |PF |EPF |D |C |C | |PF |EPF |D |C | |Chief Complaint | | | | | | | | | | | |Brief HPI | | | | | | | | | | | |Extended HPI | | | | | | | | | | | |Problem Pertinent (ROS) | | | | | | | | | | | |Extended (ROS) | | | | | | | | | | | |Complete (ROS) | | | | | | | | | | | |Pertinent PFSH | | | | | | | | | | | |Complete PFSH | | | | | | | | | | | |EXAMINATION |PF |EPF |D |C |C | |PF |EPF |D |C | |Problem Focused | | | | | | | | | | | |Expanded Problem Focused | | | | | | | | | | | |Detailed | | | | | | | | | | | |Comprehensive | | | | | | | | | | | |MEDICAL DECISION MAKING: |S |S |L |M |H | |S |L |M |H | |Straightforward | | | | | | | | | | | |Low Complexity | | | | | | | | | | | |Moderate Complexity | | | | | | | | | | | |High Complexity | | | | | | | | | | | |
Types of levels of H & E Complexity of MDM
PF = Problem Focused S = Straightforward
EPF = Expanded Problem Focused L = Low Complexity
D = Detailed M = Moderate Complexity
C = Comprehensive H -= High Complexity
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