Evaluation and Coding Template - established office visit (nonscripted)

E/M Level of Service Determination
E/M	History [table]	Exam [table]	Medical Decision Making [table]	Time [guidelines]	E/M	History [table]	Exam [table]	Medical Decision Making [table]	Time [guidelines]
Established Outpatient Visit	New Outpatient Visit
2 of 3 key components (Hx, PE, MDM) required OR Time requirement fulfilled	3 of 3 key components (Hx, PE, MDM) required OR Time requirement fulfilled
99211	Physician's presence not required	5 min	99201	Problem focused	Problem focused	Straighforward	10 min
99212	Problem focused	Problem focused	Straighforward	10 min	99202	Extended problem focused	Extended problem focused	Low	20 min
99213	Extended problem focused	Extended problem focused	Low	20 min	99203	Detailed	Detailed	Low	30 min
99214	Detailed	Detailed	Moderate	25 min	99204	Comprehensive	Comprehensive	Moderate	45 min
99215	Comprehensive	Comprehensive	High	40 min	99205	Comprehensive	Comprehensive	High	60 min
Subsequent Hospital Visit	Initial Hospital Visit/Observation Care
2 of 3 key components (Hx, PE, MDM) required OR Time requirement fulfilled	3 of 3 key components (Hx, PE, MDM) required OR Time requirement fulfilled
99231	Problem focused	Problem focused	Straighforward	15 min	99221 99218 99234	Detailed	Detailed	Straightforward	30 min
99232	Extended problem focused	Extended problem focused	Moderate	25 min	99222 99219 99235	Comprehensive	Comprehensive	Moderate	50 min
99233	Detailed	Detailed	High	35 min	99223 99220 99236	Comprehensive	Comprehensive	High	70 min
Emergency Care Services
3 of 3 key components (Hx, PE, MDM) required
99281	Problem focused	Problem focused	Straightforward	n/a
99282	Extended problem focused	Extended problem focused	Low	n/a
99283	Extended problem focused	Extended problem focused	Moderate	n/a
99284	Detailed	Detailed	Moderate	n/a
99285	Comprehensive	Comprehensive	High	n/a

History [guidelines]
Type of History	Chief Complaint [guidelines]	HPI [guidelines]	Past/Family/Social Hx [guidelines]	ROS [guidelines]
Problem focused	Yes	Brief (1 - 3 elements)	No	No
Extended problem focused	Yes	Brief (1 - 3 elements)	No	Pertinent: ≥ 1 systems
Detailed	Yes	Extended (≥ 4 elements) or status of 3 chronic/inactive problems	Pertinent (1 of 3)	Extended: 2 - 9 systems
Comprehensive	Yes	Extended (≥ 4 elements) or status of 3 chronic/inactive problems	Complete (2 - 3 of 3)	Complete: ≥ 10 systems

Physical Examination [guidelines]
Level	1997 Guidelines	1995 Guidelines
Problem focused	1 to 5 bullets	a limited examination of the affected body area or organ system (exam of 1 body area or organ system documented)
Extended problem focused	6 - 11 bullets	limited examination of the affected body area or organ system and other symptomatic or related organ system(s) (exam of 2-7 body areas or organ systems documented)
Detailed	≥ 12 bullets	an extended examination of the affected body area(s) and other symptomatic or related organ system(s) (exam of 2-7 body areas or organ systems documented)
Comprehensive	≥ 2 bullets from each of 9 organ systems	a general multi-system examination (examination of 8 or more organ systems)

1997 Physical Examination Guidelines
System/Body Area	Elements of Examination	System/Body Area	Elements of Examination
Constitutional (2)	Measurement of any three of the following seven vital signs: 1) sitting or standing blood pressure, 2) supine blood pressure, 3) pulse rate and regularity, 4) respiration, 5) temperature, 6) height, 7) weight (May be measured and recorded by ancillary staff) General appearance of patient (eg, development, nutrition, body habitus, deformities, attention to grooming)	Eyes (3)	Inspection of conjunctivae and lids Examination of pupils and irises (eg, reaction to light and accommodation, size and symmetry) Ophthalmoscopic examination of optic discs (eg, size, C/D ratio, appearance) and posterior segments (eg, vessel changes, exudates, hemorrhages)
Ears, Nose, Mouth and Throat (6)	External inspection of ears and nose (eg, overall appearance, scars, lesions, masses) Otoscopic examination of external auditory canals and tympanic membranes Assessment of hearing (eg, whispered voice, finger rub, tuning fork) Inspection of nasal mucosa, septum and turbinates Inspection of lips, teeth and gums Examination of oropharynx: oral mucosa, salivary glands, hard and soft palates, tongue, tonsils and posterior pharynx	Neck (2)	Examination of neck (eg, masses, overall appearance, symmetry, tracheal position, crepitus) Examination of thyroid (eg, enlargement, tenderness, mass)
Respiratory (4)	Assessment of respiratory effort (eg, intercostal retractions, use of accessory muscles, diaphragmatic movement) Percussion of chest (eg, dullness, flatness, hyperresonance) Palpation of chest (eg, tactile fremitus) Auscultation of lungs (eg, breath sounds, adventitious sounds, rubs)	Cardiovascular (7)	Palpation of heart (eg, location, size, thrills) Auscultation of heart with notation of abnormal sounds and murmurs Examination of carotid arteries (eg, pulse amplitude, bruits) Examination of abdominal aorta (eg, size, bruits) Examination of femoral arteries (eg, pulse amplitude, bruits) Examination of pedal pulses (eg, pulse amplitude) Examination of extremities for edema and/or varicosities
Chest (Breasts) (2)	Inspection of breasts (eg, symmetry, nipple discharge) Palpation of breasts and axillae (eg, masses or lumps, tenderness)	Gastrointestinal (Abdomen) (5)	Examination of abdomen with notation of presence of masses or tenderness Examination of liver and spleen Examination for presence or absence of hernia Examination (when indicated) of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses Obtain stool sample for occult blood test when indicated
Genitourinary, Male (3)	Examination of the scrotal contents (eg, hydrocele, spermatocele, tenderness of cord, testicular mass) Examination of the penis Digital rectal examination of prostate gland (eg, size, symmetry, nodularity, tenderness)	Genitourinary, Female (6)	Pelvic examination (with or without specimen collection for smears and cultures), including: Examination of external genitalia (eg, general appearance, hair distribution, lesions) and vagina (eg, general appearance, estrogen effect, discharge, lesions, pelvic support, cystocele, rectocele) Examination of urethra (eg, masses, tenderness, scarring) Examination of bladder (eg, fullness, masses, tenderness) Cervix (eg, general appearance, lesions, discharge) Uterus (eg, size, contour, position, mobility, tenderness, consistency, descent or support) Adnexa/parametria (eg, masses, tenderness, organomegaly, nodularity)
Lymphatic (4)	Palpation of lymph nodes in two or more areas: Neck Axillae Groin Other	Musculoskeletal (26)	Examination of gait and station Inspection and/or palpation of digits and nails (eg, clubbing, cyanosis, inflammatory conditions, petechiae, ischemia, infections, nodes) Examination of joints, bones and muscles of one or more of the following six areas: 1) head and neck; 2) spine, ribs and pelvis; 3) right upper extremity; 4) left upper extremity; 5) right lower extremity; and 6) left lower extremity. The examination of each given area includes (4 bullets): Inspection and/or palpation with notation of presence of any misalignment, asymmetry, crepitation, defects, tenderness, masses, effusions Assessment of range of motion with notation of any pain, crepitation or contracture Assessment of stability with notation of any dislocation (luxation), subluxation or laxity Assessment of muscle strength and tone (eg, flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements
Skin (2)	Inspection of skin and subcutaneous tissue (eg, rashes, lesions, ulcers) Palpation of skin and subcutaneous tissue (eg, induration, subcutaneous nodules,tightening)	Neurologic (3)	Test cranial nerves with notation of any deficits Examination of deep tendon reflexes with notation of pathological reflexes (eg, Babinski) Examination of sensation (eg, by touch, pin, vibration, proprioception)
Psychiatric (4)	Description of patient's judgment and insight Brief assessment of mental status including: orientation to time, place and person recent and remote memory mood and affect (eg, depression, anxiety, agitation)

Genitalia, groin, buttocks

1995 Physical Examination Components
Body Areas	Organ Systems
Head, including the face	Constitutional* (vital signs, general appearance)
Neck*	Eyes*
Chest, including breasts and axillae*	Ears, Nose, Mouth, Throat*
	Cardiovascular*
	Respiratory*
Abdomen	Gastrointestinal*
Genitourinary*
Back, including spine	Musculoskeletal*
Each extremity (up to 4)	Musculoskeletal*
Exam cannot be organized by body areas in documentation of Comprehensive Exam, only by Organ Systems	Skin*
	Neurologic*
	Psychiatric*
	Hematologic/Lymphatic/Immunologic*
* Also is considered ad organ system under 1997 guidelines

Medical Decision-Making (2 of 3 components required)
Complexity level	Problem points [table]	Data Points [table]	Risk level [table]
Straightforward	1	1	Minimal
Low	2	2	Low
Moderate	3	3	Moderate
High	≥ 4	≥ 4	High

Presenting Problems to Treating Provider
(# of diagnoses requiring active management or affecting treatment options)	Points each
Self-limited/minor (max 2)	1
Established, stable/improved	1
Established, worsening	2
New, no further w/u planned (max 1)	3
New, further w/u planned	4

Data Amount/Complexity	Points each
Review and/or order labs	1
Review and/or order X-rays	1
Review and/or orders tests (eg, PFT's, EKG, ECHO)	1
Discuss test results with performing MD	1
Personally review/interpret image, tracing, specimen	2
Order old records	1
Review and summarize old records	2

Risk level (1 element in any of the 3 categories)
Level	Presenting Problem(s)	Diagnostic Procedure(s)	Management Option(s)
Minimal	One self-limited or minor problem (e.g., insect bite, cold)	Lab tests Chest X-ray EKG/EEG Urinalysis Ultrasound/Echocardiography KOH prep	Rest Gargles Elastic bandages Superficial dressings
Low	2 or more self-limited or minor problems 1 stable chronic illness (eg, well controlled hypertension or non-insulin dependent diabetes, cataract, BPH) Acute uncomplicated illness or injury (eg, cystitis, allergic rhinitis, simple sprain)	Physiologic tests not under stress (eg, pulmonary function tests) Non-cardiovascular imaging studies with contrast (eg, barium enema) Superficial needle biopsies Skin biopsies	Over-the-counter drugs Minor surgery with no identified risk factors Physical therapy Occupational therapy IV fluids without additives
Moderate	1 or more chronic illnesses w/mild exacerbation, progression or side effects of treatment 2 or more stable chronic illnesses Undiagnosed new problem w/uncertain prognosis (eg, lump in breast) Acute illness with systemic symptoms (eg, pyelonephritis, pneumonitis, colitis) Acute complicated injury (eg, head injury w/ brief loss of consciousness)	Physiologic tests under stress (eg, cardiac stress test, fetal contraction stress test) Diagnostic endoscopies w/no identified risk factors Deep needle or incisional biopsy Cardiovascular imaging studies w/contrast, no identified risk factors (eg, arteriogram, cardiac catheterization) Obtain fluid from body cavity (eg, lumbar puncture, thoracentesis, culdocentesis)	Minor surgery with identified risk factors Elective major surgery (open, percutaneous, or endoscopic) w/no identified risk factors Prescription drug management Therapeutic nuclear medicine IV fluids with additives Closed treatment of fracture or dislocation w/o manipulation
High	1 or more chronic illnesses w/severe exacerbation, progression, side effects of treatment Acute or chronic illnesses or injuries that pose a threat to life or bodily function (eg, multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness w/ potential threat to self or others, peritonitis, acute renal failure Abrupt change in neurologic status (eg, seizure, TIA, weakness, or sensory loss)	Cardiovascular imaging studies w/contrast with identified risk factors Cardiac eletrophysiological tests Diagnostic endoscopies w/identified risk factors Discography	Elective major surgery (open, percutaneous or endoscopic) w/identified risk factors Emergency major surgery (open, percutaneous or endoscopic) Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate or to de-escalate care because of poor prognosis

Documentation of an Encounter Dominated by Counseling or Coordination of Care

In the case where counseling and/or coordination of care dominates (more than 50%) of the physician/patient and/or family encounter (face-to-face time in the office or other or outpatient setting, floor/unit time in the hospital or nursing facility), time is considered the key or controlling factor to qualify for a particular level of E/M services.

The "recommended" times provided for most, but not all E/M encounters are merely a guide. Some encounters may take longer than their allotted times, while others may take less than the time allowed. It is NOT necessary to use the allotted time for any particular encounter if coding level is based on the documentation of the three key components. If coding level is based on time, the following is required:

The physician MUST spend the entire allotted time face-to-face with the patient.
At least HALF of that time must be used for "counseling and coordination of care."
The duration of the encounter MUST be documented in the record.
The record MUST explicitly state that over half the time was spent on counseling and coordination of care.
The nature of the counseling and coordination of care MUST be documented.

Example: A total of *** minutes were spent face-to-face with the patient during this encounter and over half of that time was spent on counseling and coordination of care. We discussed the following in depth:

Guideline: If the physician elects to report the level of service based on counseling and/or coordination of care, the total length of time of the encounter (face-to-face or floor time, as appropriate) should be documented and the record should describe the counseling and/or activities to coordinate care.

Documentation Guidelines - History

Guideline: The CC, ROS and PFSH may be listed as separate elements of history, or they may be included in the description of the History of the Present Illness.
Guideline: If the physician is unable to obtain a history from the patient or other source, the record should describe the patient's condition or other circumstance which precludes obtaining a history

Documentation Guidelines - Chief Complaint (CC)

The Chief Complaint is a concise statement describing the symptom, problem, condition, diagnosis, physician recommended return, or other factor that is the reason for the encounter, usually stated in the patient's words.

Guideline: The medical record should clearly reflect the chief complaint.
Guideline: The Chief Complaint may be listed as a separate element of the history, or it may be included in the description of the History of the Present Illness.

Documentation Guidelines - History of Present Illness (HPI)

The HPI is a chronological description of the development of the patient's present illness from the first sign and/or symptom or from the previous encounter to the present. It includes the following elements:

location,
quality
severity,
duration,
timing,
context,
modifying factors, and
associated signs and symptoms.

Guideline: For a brief HPI, the medical record should describe one to three elements of the present illness.
Guideline: For an extended HPI, the medical record should describe at least four elements of the present illness, or the status of at least three chronic or inactive conditions.
Guideline: The Chief Complaint may be listed as a separate element of the history, or it may be included in the description of the History of the Present Illness.
Guideline: The PFSH may be listed as a separate element of the history, or it may be included in the description of the History of the Present Illness.

Documentation - Past/Social/Family History (PFSH)

The PFSH consists of a review of three areas:

past history (the patient's past experiences with illnesses, operations, injuries and treatments);
family history (a review of medical events in the patient's family, including diseases which may be hereditary or place the patient at risk); and
social history (an age appropriate review of past and current activities).

For certain categories of E/M services that include only an interval history, it is not necessary to record information about the PFSH. Those categories are subsequent hospital care, follow-up inpatient consultations and subsequent nursing facility care.

A pertinent PFSH is a review of the history area(s) directly related to the problem(s) identified in the HPI.

A complete PFSH is of a review of two or all three of the PFSH history areas, depending on the category of the E/M service. A review of all three history areas is required for services that by their nature include a comprehensive assessment or reassessment of the patient. A review of two of the three history areas is sufficient for other services.

Guideline: The PFSH may be listed as a separate element of the history, or it may be included in the description of the History of the Present Illness.
Guideline: A PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record, or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:

describing any new PFSH information or noting there has been no change in the information; and
noting the date and location of the earlier PFSH.

Guideline: The PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.
Guideline: At least one specific item from one of the three history areas must be documented for a pertinent PFSH.
Guideline: At least one specific item from two of the three history areas must be documented for a complete PFSH for the following categories of E/M services:

office or other outpatient services, established patient;
emergency department;
domiciliary care, established patient; and
home care, established patient.

Guideline: At least one specific item from each of the three history areas must be documented for a complete PFSH for the following categories of E/M services:

office or other outpatient services, new patient;
hospital observation services;
hospital inpatient services, initial care;
consultations;
comprehensive nursing facility assessments;
domiciliary care, new patient; and
home care, new patient.

Documentation Guidelines- Review of Symptoms (ROS)

A ROS is an inventory of body systems obtained through a series of questions seeking to identify signs and/or symptoms which the patient may be experiencing or has experienced. For purposes of ROS, the following systems are recognized:

Constitutional symptoms (e.g., fever, weight loss)
Eyes
Ears, Nose, Mouth, Throat
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Musculoskeletal
Integumentary (skin and/or breast)
Neurological
Psychiatric
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic

A problem pertinent ROS inquires about the system directly related to the problem(s) identified in the HPI.
An extended ROS inquires about the system directly related to the problem(s) identified in the HPI and a limited number of additional systems.
A complete ROS inquires about the system(s) directly related to the problem(s) identified in the HPI plus all additional body systems.

Guideline: For a pertinent ROS, he patient's positive responses and pertinent negatives for the system related to the problem should be documented.
Guideline: For an extended ROS, the patient's positive responses and pertinent negatives for two to nine systems should be documented.
Guideline: For a complete ROS, at least ten organ systems must be reviewed. Those systems with positive or pertinent negative responses must be individually documented. For the remaining systems, a notation indicating all other systems are negative is permissible. In the absence of such a notation, at least ten systems must be individually documented.
Guideline: The ROS may be listed as a separate element of the history, or it may be included in the description of the History of the Present Illness.
Guideline: An ROS obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record, or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:

describing any new ROS information or noting there has been no change in the information; and
noting the date and location of the earlier ROS.

Guideline: The ROS may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.

Documentation of Examination

The levels of E/M services are based on four types of examination:

Problem Focused -- a limited examination of the affected body area or organ system.
Expanded Problem Focused -- a limited examination of the affected body area or organ system and any other symptomatic or related body area(s) or organ system(s).
Detailed -- an extended examination of the affected body area(s) or organ system(s) and any other symptomatic or related body area(s) or organ system(s).
Comprehensive -- a general multi-system examination, or complete examination of a single organ system and other symptomatic or related body area(s) or organ system(s).

A general multi-system examination or a single organ system examination may be performed by any physician regardless of specialty. The type (general multi-system or single organ system) and content of examination are selected by the examining physician and are based upon clinical judgement, the patient's history, and the nature of the presenting problem(s).

To qualify for a given level of multi-system examination, the following content and documentation requirements should be met:

Level	Requirements
Problem Focused Examination	Should include performance and documentation of one to five elements identified by a bullet in one or more organ system(s) or body area(s).
Expanded Problem Focused Examination	Should include performance and documentation of at least six elements identified by a bullet in one or more organ system(s) or body area(s).
Detailed Examination	Should include at least six organ systems or body areas. For each system/area selected, performance and documentation of at least two elements identified by a bullet is expected. Alternatively, a detailed examination may include performance and documentation of at least twelve elements identified by a bullet in two or more organ systems or body areas.
Comprehensive Examination	Should include at least nine organ systems or body areas. For each system/area selected, all elements of the examination identified by a bullet should be performed, unless specific directions limit the content of the examination. For each area/system, documentation of at least two elements identified by a bullet is expected.

Guideline: Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. A notation of "abnormal" without elaboration is insufficient.
Guideline Abnormal or unexpected findings of the examination of any asymptomatic body area(s) or organ system(s) should be described.
Guideline: A brief statement or notation indicating "negative" or "normal" is sufficient to document normal findings related to unaffected area(s) or asymptomatic organ system(s).