Name of Patient_________________________________________ Pt.

#___________________ Date_________________________

Physician______________________________________________ Location/Office
Office Consults New Patient Office Visits Established Patient Office Visits
Code Code History Exam Decis. Time Code History Exam Decis. Time
99241 99201 PF PF S 15/10 min. 99211 -- -- -- 5 min.
99242 99202 EPF EPF S 30/20 min. 99212 PF PF S 10 min.
99243 99203 D D LC 40/30 min. 99213 EPF EPF LC 15 min.
99244 99204 C C MC 60/45 min. 99214 D D MC 25 min.
99245 99205 C C HC 80/60 min. 99215 C C HC 40 min.
3 of 3 required 2 of 3 required


DOCUMENTED HISTORY
Chief Complaint:______________________________________________________________
History of Present Illness(HPI):_________________________________________________________________________________
________________________________________________________________________
Location Severity Timing Associated signs/symptoms Quality Duration Context Modifying factors
____Brief HPI: 1-3 elements OR 1-2 chronic/inactive conditions ____Extended HPI: 4+ elements OR 3+ chronic/inactive conditions
Review of Systems (ROS):
Constitutional ___neg:pos______ Respiratory ___neg;pos______ Skin/breasts ___neg;pos_______________
Eyes ___neg:pos______ Gastrointestinal ___neg;pos______ Neurologic ___neg;pos_______________
ENT/Mouth ___neg:pos______ Genitourinary ___neg;pos_______ Psychiatric ___neg;pos_______________
Cardiovasular ___neg;pos______ Musculoskeletal ___neg/pos_______ Endocrine ___neg/pos_______________
Heme/Lymph ___neg:pos____ Allergy/Immun ___neg:pos_______

PFSH __________________________________________________________________________________________________


History Summary: 3 out of 3 required History ROS PFSH
Problem Focused 1-3 HPI (or status of 1-2
chronic diseases)
- -
Expanded Problem-Focused 1 -
Detailed 4+ HPI (or status of 3+ chronic
diseases)
2 9 1
Comprehensive 10+ 2 (estab.) 3 (new)


EXAM:
The EX of a given area includes: Inspection/palp, ROM, Stability/laxity and muscle strength/tone



Exam Summary: 1997 guidelines 1995 guidelines
Problem Focused 1-5 bullets from 1+ systems 1 system
Expanded Problem-Focused 6+ bullets from 1+ systems 2-7 systems
Detailed 12+ bullets from 2+ systems 2-7 systems (4x4 in systems)
Comprehensive 18+ bullets from 9+ systems (at least 2 from each 9+ systems) 8+ systems


COMPLEXITY OF MEDICAL DECISION MAKING
Number of diagnosis/management options: Dx/Mx Options Score
______Self-limited, minor problem (max = 2) = 1 1 (minimal) Straightforward
______Each established; previously Dx problem = 1 2 (limited) Low Complexity
______Add 1 for each established problem inadequately = 1 3 (multiple) Moderate Complexity
controlled, worsening, etc. 4 (extensive) High Complexity
______New problem, no additional work-up planned (max. = 3) = 3
______New problem, additional work-up planned = 4
______Total

Amount and complexity of data obtained/ analyzed/reviewed: Data Score
______Review/order lab tests (CPT 80002-89399) = 1 1 (minimal/none) - Straightforward
______Review/order routine X-rays (CPT 70010-79999) = 1 2 (limited) - Low Complexity
______Review/order medical studies (CPT 90700-99199) = 1 3 (moderate) - Mod. Complexity
______Independent second interp of specimen/image/tracing = 2 4 (extensive) - High Complexity
______Discussion of test results with performing physician = 1
______Decision to obtain old records = 1
______Review and summarization of old records = 2
______Total

Risk Score
Risk Level Examples
Minimal Problems: One self-limited/minor prob. (e.g. common cold, insect bite, tinea corporis)
Dx proc: Venipuncture, CXR, EKG, UA, U/S (e.g. Echo), KOH prep
Mx options: Rest, gargles, elastic bandages, superficial dressings
Low Problems: > 1self-limited/minor prob., one stable chronic illness, acute uncomplicated illness/injury
Dx proc: Pulmonary Function Tests, barium enema, superficial needle biopsy, arterial puncture, skin biopsy
Mx options: OTC drugs, minor surgery (no risk factors), PT. OT, IV fluids w/o additives
Moderate Problems: 1+ chronic illnesses w/mild Rx side effects; >1 stable chronic illnesses; new prob., no Dx, (e.g.
breast lump); acute illness w/systemic Sx (e.g. pyelonephritis); Acute complicated injury (e.g. head injury w/
brief loss of consciousness)
Dx proc: Cardiac stress test, fetal contraction stress test, Dx endoscopy w/no risk factors, deep needle or
incisional biopsy, arteriogram, lumbar puncture, thoracentesis
Mx options: Minor surgery w/risk factors, Rx drug management, IV fluids w/additives, closed Mx of
fracture/dislocation w/o manipulation
High Problems: 1+ chronic illnesses w/severe exacerbation, progression or side effects of Tx; potentially life-
threatening illnesses (e.g. acute MI, progressive severe RA, potential threat of suicide); abrupt neurologic
change (e.g. seizure, TIA, weakness or sensory loss)
Dx proc: Dx endoscopy w/risk factors
Mx options: Parenteral controlled substances, Rx needing intensive monitoring for toxicity, DNR decision

Medical Decision Making Summary: 2 out of 3 required
Final Results for Complexity
1.
# Dx / Mx options

< 1
Minimal
2
Limited
3
Multiple
>4
Extensive
2. Highest Risk Minimal Low Moderate High
3. Amt. & comp. of data
< 1 Minimal/
low
2
Limited
3
Multiple
4
Extensive
Type of Decision- Making
STRAIGHT-
FORWARD
LOW-
COMPLEX
MOD-
COMPLEX
HIGH-
COMPLEX
LEVELS 1 & 2 3 4 5

Time:
Total visit time ____________________
Total counseling time_______________
(required by LG Internal Audit Department if more than 50 percent of the face-to-face time was spent in counseling or
coordination of care - documentation of the extent of counseling and coordination of care is required)

Billed E & M Code: _______________ Audit E & M Code________________