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).

2 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: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.

3 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.

4 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.

5 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. 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.

6 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.

7 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.

8 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)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.

9 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)

10 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) 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)