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EVALUATION MANAGEMENT REVIEW SHEET

ESTABLISHED PATIENT (2 of 3 COMPONENTS)

HISTORY OF PRESENT ILLNESS Location Quality Severity Duration Timing Context Modifying Factors Associated Signs & Symptoms

EXAM N/A 1995 BODY AREAS EXAM Genitalia/Groin/Buttocks Right Upper Extremity Left Upper Extremity Right Lower Extremity Left Lower Extremity

REVIEW OF SYSTEMS AND EXAMINATION

ROS Constitutional Eyes ENT Cardiovascular Respiratory Gastrointestinal Genitourinary EXAM ROS Skin/Breast Musculoskeletal EXAM Neurologic Psychiatric Hem/Lymph Endocrine Allergy/Imm N/A N/A Head, incl. Face Neck Chest Abdomen Back/Spine EXAM ROS All Others Neg

A: HISTORY TYPE: Select the column with all 3 items circled; if the circles are not in the same column, pick the column furthest to the left HPI - 1995 HPI - 1997 ROS P F S History Interval History History Type Brief 1 - 3 Extended > 4 Extended > 4 or status of 3 chronic/inactive diseases Brief 1 - 3 None Problem Pertinent Extended 2 - 9 Complete > 10 None None Pertinent 1 Complete 2-3 Score based on HPI & ROS for subs hosp, subs NF, home visit, domiciliary or rest home. Problem-Focused Expanded Problem-Focused Detailed Comprehensive

score on page 2 in History Type

B: EXAMINATION TYPE - 1997 exam guidelines must be used if HPI extended d/t status 3+ chronic/inactive conditions. Select the highest level of examination. Affected Area + 2-7 Areas, 1995 Guidelines Affected Area 8+ Areas Body Areas 1 to 6 Others More Detail Affected System + 2-7 Systems, 8+ Systems or Complete 1995 Guidelines Affected System Systems 1 to 6 Others More Detail Single System Exam 12+ bulleted elements in 2+ bulleted elements for 1997 Guidelines, 1-5 bulleted elements 6-11 bulleted elements Gen Multisystem 2+ Systems each of 9+ Systems Examination Type Problem-Focused Expanded Problem-Focused Detailed Comprehensive C: DECISION MAKING: DIAGNOSIS/MANAGEMENT OPTIONS: Identify each problem evaluated in the record and classify; enter total number of each type of problem Problem Categories Self-limited or minor (stable, improving, or worsening) Established Diagnosis/Problem, stable, improved Established Diagnosis/Problem, worsening New Problem, NO additional work-up planned New Problem, additional work-up planned/consultation

(MAX = 1)

score on page 2 in Examination Type

Number

(MAX = 2)

Points = Score

1 1 2 3 4 Total score on page 2 in Decision Making Type Table

TYPE OF DATA Points Type of Data 1 Review and/or order clinical lab tests 1 Review and/or order tests in 7XXXX series of CPT codes Review and/or order tests in 9XXXX series of CPT codes 1 Discuss test results with performing/interpreting physician 1 Independent review of image, tracing, or specimen 2 1 Decision to obtain old records and/or decision to obtain history from others 2 Review AND summarize old records and/or history obtained from others Total score on page 2 in Decision Making Type Table

Page 1 of 2

Revised 02/05/10

CPT codes, descriptors, and other data only are copyright 2009 American Medical Association (or such other publication of CPT). All rights reserved. Applicable FARS/DFARS apply.

EVALUATION MANAGEMENT REVIEW SHEET ESTABLISHED PATIENT (2 of 3 COMPONENTS) C: DECISION MAKING 2/3 (CONT'D) RISK ASSESSMENT: Use the examples in the Table of Risk for guidance. For each area (first column), select the highest level of risk documented. For OVERALL RISK, pick the column with the circle furthest to the right. Presenting Problem(s) Diagnostic Procedure(s) Management Option(s) Overall Risk Minimal Minimal Minimal Minimal = 1 Low Low Low Low = 2 Moderate Moderate Moderate Moderate = 3 High High High High = 4

score below in Decision Making Type Table

DECISION MAKING TYPE: Circle the final score from the charts and tables (1,2,3). Draw a line down from any column with 2 or 3 circles, and circle the type in that column. Otherwise, draw a line from the circle in the middle column. Diagnosis/Management Options Type of Data Overall Risk Type of Decision Making 1 = Minimal <1 = Minimal 1 = Minimal

Straightforward

2 = Limited 2 = Limited 2 = Low Low

3 = Multiple 3 = Moderate 3 = Moderate Moderate

4 = Extensive 4 = Extensive 4 = High High

score below in Selection of

CPT Code, Decision Making Type

SELECTION OF CPT CODE: If a column has 2 or 3 items circled, choose the code in that column. Otherwise, draw a line down from the next circle to the left of the column with the circle at the highest level and select the code in that column.

QUICK REFERENCE, ESTABLISHED PATIENT CPT CODES

Office Visit, Established Patient History Type Examination Type Decision Making Type CPT Codes Subsequent Hospital History Type Examination Type Decision Making Type Hosp Subseq CPT Codes Subsequent Nursing Facility History Type Examination Type Decision Making Type CPT Codes Home Visit, Established Patient History Type Examination Type Decision Making Type CPT Codes Problem Focused Interval Expanded PF Interval Problem Focused Expanded PF Straightforward Low 99347 99348 Detailed Interval Detailed Moderate 99349 Comprehensive Interval Comprehensive High 99350 Problem Focused Interval Problem Focused Straightforward 99307 Expanded PF Interval Expanded PF Low 99308 Detailed Interval Detailed Moderate 99309 Comprehensive Interval Comprehensive High 99310 Problem Focused Interval Problem Focused Straightforward/Low 99231 Expanded PF Interval Expanded PF Moderate 99232 Detailed Interval Detailed High 99233 N/A N/A N/A 99211 Problem Focused Problem Focused Straightforward 99212 Expanded PF Expanded PF Low 99213 Detailed Detailed Moderate 99214 Comprehensive Comprehensive High 99215

Domiciliary/Rest Home/Home Visit, Established Patient History Type Examination Type Decision Making Type Domiciliary/Rest Home CPT Cod Home Visit CPT Codes Problem Focused Interval Problem Focused Straightforward 99334 99347 Expanded PF Interval Expanded PF Low 99335 99348 Detailed Interval Detailed Moderate 99336 99349 Comprehensive Interval Comprehensive Moderate/High 99337 99350 Page 2 of 2

Revised 02/05/10

CPT codes, descriptors, and other data only are copyright 2009 American Medical Association (or such other publication of CPT). All rights reserved. Applicable FARS/DFARS apply.

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