Choosing the Appropriate Outpatient E/M Code

1 Choosing the Appropriate Outpatient E/M Code1. HistoryComplete the following chart by marking the entry in the farthest right column which best describes the History of Present Illness(HPI), Review of Systems (ROS), and the Past Family and Social History (PFSH). If one column contains three marks, the typeof history is indicated at the bottom of the column. If no column contains three marks, the column containing the mark farthest tothe left identifies the type of history. Once the type of history is determined, record it in the Appropriate grid in Section (history of present illness) elements:n Locationn Severityn Timingn Modifying factorsn Qualityn Durationn Contextn Associated signs and symptomsBrief(1-3)Brief(1-3)Extended(4 or more)Extended(4 or more)ROS (review of systems):n Constitutionaln Ears, nose,n GIn Integumentaryn Endo(wt loss, etc)mouth, throatn GUI(skin, breast)n Hem/lymphn Eyesn Card/vascn Musculon Neuron All immunon Respn Psychn All others negativeNonePertinent toproblem(1 system)Extended(2-8systems))Complete**PF SH (past medical, family, social history) areas.

2 N Past history (the patient s past experiences with illnesses, operations, injuries, and treatments)n Family history (a review of medical events in the patient s family, including diseases which may behereditary or place the patient at risk.)n Social history (an age Appropriate review of past and current activities.)NoneNonePertinent(1 historyarea)Complete*(2 or 3historyareas)* Complete PFSH:2 hx areas: a) Estab pts, office (outpt) care, domiciliary care; home care b) Emergency dept c) Subseq nursingfacility care3 hx areas: a) New pts, office (outpt) care; domiciliary care, home care b) Consultations c) initial hospital care d)Hospital observation e) Comprehensive nursing facility assessmentsPROBLEMFOCUSEDEXPANDEDPROBLEM FOCUSEDDETAILEDCOMPRE-HENSIVE** 10 or more systems, or some systems with statement all others negative 2.

3 ExaminationUse the following grid to determine the type of examination. Note that the General Multi-System Exam section on the frontpage of the ACR template corresponds to the organ systems and body areas. The Joint Exam and Spine Exam sections on theback page of the ACR template correspond to the single organ system exam for the musculoskeletal system. Once the type ofexamination is determined, record it in the Appropriate grid in Section areas:n Head, including facen Chest, breasts, axillaen Abdomenn Back, including spinen Neckn Genitalia, groin, buttocksn Each extremityOrgan systems:n Constitutionaln Ears, nosen Respn Musculon Psych( , vitals, gen app)mouth, throatn GIn Skinn Hem/lymph/immn Eyesn Cardiovascularn GUn Neuro 1 bodyarea orsystem Up to 7systems Up to 7systems(in moredetail thanExpandedProblemFocused) 8 or moresystemsORCompleteexam ofsinglesystemPROBLEMFOCUSEDEXPANDEDPROB LEMFOCUSEDDETAILEDCOMPRE-HENSIVE3.

4 Medical Decision MakingMedical Decision Making involves calculating the number of diagnoses or treatment options, amount and/or complexity of datareviewed, and the level of risk. Use the following tables to calculate these factors and record the results in the table labeled FinalResult for Complexity. When the final result for complexity is determined, record it in the Appropriate grid in Section Number of Diagnoses or Treatment OptionsIdentify each problem or treatment option mentioned in the record. Enter thenumber in each of the categories in Column B in the table below. (There aremaximum numbers in two categories.)AB X C = DProblem(s) StatusNumberPointsResultSelf-limited or minor(stable, improved or worsening)Max = 21 Est problem (to examiner); stable, improved1 Est.

5 Problem (to examiner); worsening2 New problem (to examiner); no additionalworkup plannedMax = 13 New problem (to examiner); add. workupplanned4 TOTALM ultiply the number in columns B& C and put the product in column a total for column total to Line B in Final Result for Complexity (table on reverse side)All Physician s Current Procedural Terminology (CPT) five-digit numeric codes, descriptions andnumeric modifiers are Copyright 1998 American Medical Association. All Rights Amount and/or Complexity of Data ReviewedFor each category of reviewed data identified, circle the number in the pointscolumn. Total the DataPointsReview 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 otherthan patient1 Review and summarization of old records and/or obtaining history fromsomeone other than patient and/or discussion of case with another healthcare provider2 Independent visualization of image, tracing or specimen itself (not simplyreview of report)2 TOTALB ring total to Line B in Final Result for Complexity (table on reverse side)

6 See Reverse Side to Complete Medical Decision MakingSupported by an educational grant from Searle and Decision Making (Continued) Risk of Complications and/or Morbidity or MortalityUse the risk table below as a guide to assign risk factors. It is understood that the table below doesnot contain all specific instances of medical care; the table is intended to be used as a guide. Circlethe most Appropriate factor(s) in each category. The overall measure of risk is the highest levelcircled. Enter the level of risk on Line C in Final Result for Complexity (table below).Level of RiskPresenting Problem(s) or Number of Diagnosesand/or ComplicationsDiagnostic Procedure(s) Ordered and/orAmount of Data to be Obtained orReviewedManagement Options SelectedMinimal One self limited or minor problem ( , rash ororal ulcers) Laboratory tests requiringvenipuncture Chest X-ray Plain X-rays of hands and/or feet Urinalysis Non-invasive diagnostic procedures( , EKG, ultrasound) Rest Splints SunscreenLow Two or more self-limited or minor problems orsymptoms One stable chronic illness ( , well controlledOA, gout) Acute uncomplicated illness or injury ( , simplesprain)

7 MRI/CT Skin biopsies Physical Therapy Occupational Therapy Tendon Injection OTC Drugs TENS UnitModerate One or more chronic illnesses with mildexacerbation, progression or side effects oftreatment Two or more stable chronic illnesses Undiagnosed new problem with uncertainprognosis ( , septic joint) Acute illness with systemic symptoms ( ,pyelonephritis, pneumonitis, colitis) Acute complicated injury ( , vertebralcompression fracture) Diagnostic endoscopies with noidentified risk factors Muscle biopsy Arthroscopy Arthrocentesis Data to be obtained/reviewedrequiring at least 10 minutes ofphysician time One or Two Prescription Drugs Joint InjectionsHigh One or more chronic illnesses with severeexacerbation, progression or side effects oftreatment Acute or chronic illnesses or injuries that pose athreat to life or bodily function ( , progressivesevere RA) An abrupt change in neurologic status ( ,seizure, TIA, weakness, sensory loss)

8 Renal/lung biopsy Diagnostic endoscopies withidentified risk factors Discography Data to be obtained and reviewedrequiring at least 20 minutes ofphysician time Elective major surgery with identified riskfactors Emergency major surgery Administration of controlled substances Drug therapy requiring intensive monitoring fortoxicity Decision not to resuscitate or to deescalatecare because of poor prognosis Parenteral drug therapy requiring intensivemonitoring and Final Result for ComplexityDraw a line down any column with 2 or 3 marks to identify the type of decision makingin that column. Otherwise, draw a line down the column with the 2nd mark from the completing this table, which classifies complexity, mark the type of decisionmaking within the Appropriate box in Table of diagnosesor treatment options 1 Minimal2 Limited3 Multiple 4 ExtensiveBAmount & complexity ofdata 1 Minimal orLow2 Limited3 Multiple 4 ExtensiveCHighest riskMinimalLowModerateHighType of decision makingSTRAIGHT-FORWARDLOWCOMPLEXMODERATE COMPLEXHIGHCOMPLEX5.

9 Determining Level of ServiceComplete this table by recording results from previoustables to determine the level of service for officeencounters with new patients, established patients Office/ConsultsEstablished OfficeRequires 3 components within a column (or choose lowest column)Requires 2 components within a column (or choose lowest column)HistoryPFEPFDCCM inimalproblem thatmay notPFEPFDCE xaminationPFEPFDCC requirepresence ofphysicianPFEPFDCC omplexity ofmedicaldecisionSFSFLMHSFLMHL evelI(99201 or99241)II(99202 or99242)III(99203 or99243)IV(99204 or99244)V(99205 or99245)I(99211)II(99212)III(99213)IV(99 214)V(99215)Supported by an educational grant from Searle and If Counseling and Coordination of CareConstitute More than 50 % of the Visit Time:If counseling and coordination of care dominate the encounter, time may be used to determinethe level of service.

10 Documentation should refer to prognosis, differential diagnosis, risks,benefits of treatment, instructions, compliance, risk reduction or discussion with another healthcare should: Reveal total face-to-face time Describe the content of counseling or coordinating care Reveal that more than half the time of the encounter was spent counseling andcoordinating these criteria are met, the following times for the entire visit (not just time spent in counselingor coordination of care) correspond with these code levels:New Patient (9920_)Established Patient (9921_)New or Est. Consult (9924_)n Level 1: 10 minutesn Level 1: 5 minutesn Level 1: 15 minutesn Level 2: 20 minutesn Level 2: 10 minutesn Level 2: 30 minutesn Level 3: 30 minutesn Level 3: 15 minutesn Level 3: 40 minutesn Level 4: 45 minutesn Level 4: 25 minutesn Level 4: 60 minutesn Level 5: 60 minutesn Level 5: 40 minutesn Level 5: 80 minutes